Spring Valley Health and Rehab Center

Inspectors wroteBased on interview and record review, the facility did not designate a person to serve as the director of food and nutrition services who had completed the minimum qualification requirements for the position. This practice could potentially affect all 35 residents residing in the facility. The facility's Dietary Manager (DM) M does not have required certifications for the Dietary Manager role, there is no full time Registered Dietician, and the facility does not have a waiver in place or on file.

Inspectors wroteBased on observation, interview and record review, the facility did not maintain safe storage and sanitary environment in which food is prepared and distributed. This has the potential to affect all residents who reside in the facility. Facility staff did not monitor dishwasher temperatures consistently. Facility staff did not monitor refrigerator and freezer temperatures consistently. This is evidenced by:The facility policy titled, Policy and Procedure Manual [NAME] & Associates, Inc: Food Storage, dated 2021, states: 13. Refrigerator food storage: .b. Temperatures for refrigerators should be between 35 to 39F. Thermometers should be checked at least two times each day. 14. Frozen Foods: .b. Frozen foods must be maintained at a temperature to keep the food frozen solid. Freezer temperatures should be checked at least two times each day. [...]

Inspectors wroteBased on observation and interview, the facility did not ensure garbage and refuse were properly disposed in the outside garbage storage receptacles. This has the potential to affect all 35 residents residing in the facility. Garbage dumpsters were open on 3 different observations. This is evidenced by:According to State Operations Manual, Appendix PP: Guidance to Surveyors for Long Term Care Facilities, revised last 4-25-25, garbage receptacles should be covered to prevent the harborage and feeding of pests. On 12/1/25 at 4:30 PM, Surveyor observed garbage dumpster and recyclable containers were uncovered. On 12/2/25 at 1:01 PM, Surveyor observed with Dietary Manager (DM) M that garbage dumpster and recyclable containers were uncovered. Surveyor interviewed DM M who stated, talk to Plant Operations Director (POD) I, he handles that. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility did not establish an Infection Prevention and Control Program (IPCP) to include outcome surveillance systems to prevent the transmission of disease and infection, which has the potential to affect all 33 residents in the facility and did not perform proper infection control practices for 2 out of 2 residents observed for tube feedings (R7, R19). Facility has no surveillance system to track and monitor staff illnesses/infections. Facility had incomplete and untimely illness/infection surveillance for residents. Registered Nurse (RN) O wore same gown while going in and out of R7's room and R19's room, who were on enhanced barrier precautions. RN O did not allow the syringe to dry after rinsing it following flushing R7's Peg tube. [...]

Inspectors wroteBased on interviews and record reviews, the facility did not ensure their designated Infection Control Preventionist (ICP) completed training in infection control (IC) prior to assuming the role, without oversight by another IC trained individual. This has the potential to affect all 33 residents in the facility. An ICP is an essential component of an effective infection control program and is the person designated by the facility to be responsible for infection control. The Centers for Disease Control and Prevention (CDC), CDC's Core Infection Prevention and Control Practices for Safe Healthcare Delivery in All Settings updated October 2022, states in part, . Adherence to infection prevention and control practices is essential to providing safe and high quality patient care across all settings where healthcare is delivered . [...]

Inspectors wroteBased on observation, interview and record review, the facility did not ensure all portions of the call light system were working properly. This had the potential to affect all 35 residents. The facility's call light system is not visible in the hallways unless the corner with computer screen is in direct line of sight. Staff need to be close to screen to read who has their call light on. The call light system does not have auditory alarms. Call lights are often not answered in timely manner, resulting in injuries and interference with resident choices. Surveyor requested facility policy, and none was provided. According to Ford, Dean and [NAME], PA white paper, titled What is Average Response Time in a Nursing Home, dated 3/4/25, states: It is important for staff workers at nursing homes and assisted living centers to respond quickly when residents signal that they need assistance. [...]

Inspectors wroteBased on staff interview and record review, the facility did not provide appropriate notices for residents (R) whose Medicare Part A coverage was discontinued for 2 of 3 residents reviewed. (R5, R4) -Did not provide Advanced Beneficiary Notice (ABN) for 2 of 3 residents. (R4, R5) -Did not provide the required 2-day notice that Medicare coverage will end for 1 of 3 residents reviewed. (R5)

Inspectors wroteBased on record review and interview, the facility did not ensure residents/representatives were notified of the rate to reserve the resident's bed and was not documented in the Wisconsin Bed Hold and Notice of Transfer for 2 of 3 residents (R) (R5, R3) reviewed. R5 was transferred to the hospital on [DATE] and 11/04/25. A bed hold notice with daily rate to reserve bed and a written notice of transfer were not documented. R3 was transferred to the hospital on 3/11/25, 4/20/25, and 10/25/25. A bed hold notice with daily rate to reserve bed and a written notice transfer were not documented. R3 was transferred to the hospital on [DATE]. A notice of transfer discharge was given but did not specify reason for transfer or daily rate to reserve bed. This is evidenced by: Facility policy titled, Bed Hold and Re-Admission, with a review date of 12/2025, states in part: [...]

Inspectors wroteBased on interview and record review, the facility did not ensure a resident who entered the facility as an exception (an exempted hospital discharge) that was later found to require more than 30 days care, received a Level II resident review within 40 calendar days of admission, for one of one resident (R1). State of Wisconsin regulation 42 CFR 483.106(b)(2)(ii), If an individual who enters a nursing facility as an exception (an exempted hospital discharge) is later found to require more than 30 days of care, the State mental health or intellectual disability authority must conduct a Level II resident review within 40 calendar days of admission. R1 was admitted to the facility on [DATE] with diagnoses that include anxiety, depression, and PTSD. R1 has intact cognition and makes own decisions. [...]

Inspectors wroteBased on interview, observation and record review, facility did not implement professional standards of practice to ensure that a resident does not develop pressure injuries (PIs), receives necessary treatment and services to promote healing and prevent new PIs from developing for 1 of 3 residents (R)(R5) reviewed. R5 developed a stage 3 Pressure Injury (PI) on right buttock and a stage 3 PI on left buttock. The facility did not completely weekly assessments and update care plan with PI interventions. This is evidenced by:Facility policy titled, Pressure Injury/Skin Integrity, with a reviewed date of 12/2025, states in part: It is the policy of this facility to enable nursing staff to manage wounds and select appropriate interventions according to National Pressure Injury Advisory Panel (NPUAP). [...]

Inspectors wroteBased on observation, interview and record review, the facility did not ensure the resident environment remains free of accident hazards as possible and each resident receives adequate supervision and assistive devices to prevent accidents for 1 of 1 resident (R)(R5) reviewed. R5 had a fall; the facility did not initiate immediate intervention to prevent future falls, complete staff education and review and revise care plan fall interventions. This is evidenced by:Facility policy titled, Accidents/Falls - HDGR, with a review date of 12/2024, states in part: The facility strives to promote safety, dignity, and overall quality of life for its residents by providing an environment that is free from any hazards for which the facility has control and by providing appropriate supervision and interventions to prevent avoidable accidents. Procedure: 5. [...]

Inspectors wroteBased on observation, record review and interview, the facility did not ensure 2 of 2 residents (R) with an NG-Tube (Nasogastric) in the facility received the appropriate treatment and services to prevent complications of enteral feedings and medication administration. (R7 and R19)R19 had unlabeled/dated enteral solutions being administered. R19 and R7's Gastrostomy tube (G-tube/ feeding tube) placement was not appropriately assessed prior to medication administration. Example 1Per provided facility policy, titled Care and Treatment of Feeding Tubes, dated copyright 2024 The Compliance Store, LLC, states: Policy: It is the policy of this facility to utilize feeding tubes in accordance with current clinical standards of practice, with intervention to prevent complications to the extent possible. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure 1 (R1) of 1 resident reviewed for post-traumatic stress disorder (PTSD) received culturally competent, trauma informed care in accordance with professional standards of practice and accounting of resident's experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization of R1. R1 does not have a person-centered care plan for triggers and interventions for R1's PTSD diagnosis.

Inspectors wroteBased on interview and record review, the facility did not develop and implement an Abuse, Neglect, and Exploitation policy to prevent and identify potential abuse concerns. This had the potential to affect all residents in the facility that would need a self report made. -Facility had an abuse policy that referred to Nebraska reporting regulations instead of Wisconsin reporting regulations.

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure the residents' environment remains as free of accident hazards as possible. Two of four residents (R) reviewed for falls with history of falls (R26 and R31) did not have post fall assessments, care plan interventions updated after falls, and had subsequent falls with major injuries. R26 and R31 are being cited at actual harm. R6 and R2 did not have post fall assessments and care plan updates after falls. One resident (R14) did not have a safety assessment or care plan for leaving facility campus and traveling on a busy highway with power wheelchair. R2, R6, and R14 are being cited at severity level 2 (potential for more than minimal harm). Observations of wet floors with no wet floor signs in place to prevent accidents occurred for R21, R13, R1, R187, and R186.

Inspectors wroteBased on observation and interview, the facility did not store, prepare, distribute and serve food in accordance with professional standards for food service safety. The facility did not ensure that food that was opened was thrown out according to policy. The facility did not cover food as it was being distributed in the hallways. The facility did not ensure staff used proper hand hygiene when distributing food and that hair nets were in place. This has the ability to affect all 33 of 33 residents residing in the facility.

Inspectors wroteBased on interview and record review, the facility did not establish an Infection Control Program under which it investigates, controls, and prevents infections in the facility, and a system for recording incidents identified under the facility's Infection Control Program, including corrective action in a timely manner, for both residents and staff. This has the potential to affect all 33 residents in the facility. -The facility did not a have a clear water management process or plan in effect to prevent transmission of Legionella infection. This has the potential to effect 33 of 33 residents reviewed. -The facility did not have a tracking program in place for the early detection of infected and exposed residents (R) and staff for COVID-19 and Norovirus during an outbreak. [...]

Inspectors wroteBased on observation, interview and record review, the facility did not ensure prescription medications were administered by qualified staff. Surveyor observed Certified Nursing Assistant (CNA) apply prescribed Nystatin powder to a resident's (R) skin for 1 of 1 observation. (R187)

Inspectors wroteBased on observations, interviews and record reviews, the facility did not provide spinal precautions and treatment by professional standards of practice to maintain a resident's highest practicable level of physical well-being for 1 of 18 residents (R21) reviewed. Staff did not follow spinal precautions to manage R21's T11 fracture by not providing log rolling during repositioning while R21 was in bed. Staff did not follow physician orders to keep back brace on R21 when head of bed is over 30 degrees.

Inspectors wroteBased on observation, interview and record review, the facility did not ensure that 2 of 4 residents (R) reviewed for pressure injuries (PI) (R2 and R187) received care consistent with professional standards of practice to promote healing of existing PIs. R2 developed an unspecified injury stage PI to the left heel on 05/30/23 and an ulcer to the great right toe. On 07/09/24, the PI reoccurred to the left heel and the right great toe. On 07/09/24, a new PI occurred to the left great toe. The care plan for PI interventions was not updated since 08/14/23. R2 was not repositioned or encouraged as needed for pressure relief as instructed on the PI care plan. R187 was admitted to the facility with a stage 3 PI to the left posterior thigh. The facility did not ensure R187's buttocks/thighs were protected, did not reposition R187, and inconsistent assessments of the wounds were noted. [...]

Inspectors wroteBased on record review and interview, the facility did not ensure acceptable parameters of nutritional status to maintain usual body weight. This occurred for 1 of 1 resident reviewed for nutritional status. Resident (R) R21. R21 was not weighed weekly to assess if she was maintaining her usual body weight. R21 had significant weight loss that were not assessed appropriately. This is evidenced by: R21 was admitted on [DATE]. R21's diagnoses include fracture of T9-T10 vertebra, fracture of first lumbar vertebrae, fracture of second lumbar vertebrae, fracture of third lumbar vertebrae, fracture of fourth lumbar vertebrae, concussion without loss of consciousness, and traumatic brain injury. R21's Minimum Data Set (MDS) assessment, completed on 07/17/24, confirmed R21 scored 12 during a Brief Interview for Mental Status (BIMS), indicating moderate impaired cognition. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure 2 of 5 residents (R16, R31) were free from unnecessary medications. R16 and R31 were prescribed lorazepam as needed (PRN), beyond the 14-day limit, without a documented rationale.

Inspectors wroteBased on interviews and record reviews, the facility failed to protect a resident's right to be free from sexual abuse. The facility did not implement interventions to protect residents (R) from sexual abuse by a resident. Not implementing interventions affected 1 of 2 residents (R1) reviewed for sexual abuse. *On 03/28/24, a Certified Nursing Assistant (CNA) found R2 in R1's room. R2 was shirtless and zipping and buttoning R2's pants while in R1's bed. R1, who is cognitively impaired, stood in the middle of the room with a T-shirt and no pants. The facility did not implement appropriate interventions to prevent a second occurrence of sexual abuse from occurring. *On 04/01/24, a CNA found R2 in R1's room. R1 was in bed on R1's back. R2 was lying with R2's head next to R1's feet. [...]

Inspectors wroteBased on record review and staff interviews, the facility did not ensure Certified Nursing Assistant (CNA) received a performance review every 12 months for four of four CNAs reviewed. (CNA H, CNA M, CNA N, CNA O). The facility failed to have a system in place to ensure that performance reviews were being done for any of the facility CNAs. This had the potential to affect all 38 residents resided in the facility. This is evidenced by: On 04/25/24, a random sample of CNAs employed by the facility were selected for review for the completion of annual performance reviews. The facility provided the following information: CNA H has been employed at the facility since 11/16/20. An annual performance review could not be located. CNA M has been employed at the facility since 09/04/21. An annual performance review could not be located. CNA N has been employed at the facility since 02/13/23. [...]

Inspectors wroteBased on staff interviews and record reviews, the facility did not conduct and document a facility-wide assessment to determine what resources are necessary to care for its residents competently during both day-to-day operations and emergencies. The facility did not review and update that assessment, as necessary, and at least annually. The lack of assessment has the potential to affect all 38 residents.

Inspectors wroteBased on interview and record review, the facility did not ensure mandatory staffing data submitted from FY (Fiscal Year) Quarter 4, 2023 (July 1-September 30) to FY Quarter 1, 2024 (October 1-December 31) was complete, accurate, and auditable. This has the ability to affect the census of 38. This is evidenced by: The Payroll-Based Journal (PBJ) Staffing Data Reports generated quarterly document the facility triggered for Failed to have Licensed Nursing Coverage 24 Hours/Day from July 1, 2023, to December 31, 2023, for specified dates. The specified dates are as follows: FY Quarter 4, 2023: 07/16, 08/05, 08/13/, 08/19, and 09/24. FY Quarter 1, 2024: 10/22, 10/31, 12/04, 12/25, and 12/31. The facility did not produce the data that was submitted during this time frame for the specified dates therefore the Surveyor was not able to audit the exact document(s) that were submitted. [...]

Inspectors wroteBased on interviews and record review, the facility did not implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act when an allegation of sexual abuse was not reported immediately but not later than 2 hours after the allegation is made, to the administrator of the facility and to other officials (including to the State Survey Agency and law enforcement where state law provides for jurisdiction in long-term care facilities) in accordance with state law for 2 of 2 abuse allegations reviewed for Resident (R1). On 03/28/24, a Certified Nursing Assistant (CNA) found R2 in R1's room. R2 was shirtless, zipping and buttoning R2's pants while in R1's bed. R1 stood in the middle of the room with a T-shirt and no pants. Allegation not reported to State Agency or Law Enforcement. [...]

Inspectors wroteBased on interviews and record review, the facility did not ensure that 1 of 1 resident (R) alleged violations of abuse were not thoroughly investigated (R1). On 03/28/24, a Certified Nursing Assistant (CNA) found R2 in R1's room. R2 was shirtless, zipping and buttoning R2's pants while in R1's bed. R1 stood in the middle of the room with a T-shirt and no pants. The facility did not investigate this incident. On 04/01/24, a CNA found R2 in R1's room. R1 was in bed on R1's back. R2 was lying with R2's head next to R1's feet, R2's feet on the floor with R2's legs off the bed and pants and brief pulled all the way down to R2's feet with bare buttocks on the bed next to R1's waist, and R2's penis was exposed. The facility did not conduct a thorough investigation.

Inspectors wroteBased on record review and interviews, the facility did not ensure 2 out of 5 Certified Nursing Assistants (CNA), (CNA H, CNA N), employed at the facility for more than one year received a minimum of 12 hours of in-service training each year. This has the potential to affect all 38 residents in the facility. This is evidenced by: On 04/25/24, Surveyor requested in-service training hours for CNA H and CNA N for review. CNA H's date of hire is 11/16/20, and the facility did not provide 12 hours of in-service training, which included communication, behavioral health, and dementia care. CNA N's date of hire is 02/13/23, and the facility did not provide 12 hours of in-service training, including communication, behavioral health, and dementia care. Surveyor was unable to total yearly training hours for CNA H and CNA N due to the documents provided being unreadable. [...]

Inspectors wroteBased on observations, interview and policy review, the facility did not store food under sanitary conditions. This has the potential to affect 27 of 31 residents. Chicken salad in the refrigerator was not discarded on or before the expiration date. This is evidenced by: On 06/19/23 at 9:50 AM, Surveyor observed chicken salad dated 05/29/23 in refrigerator number 2. Note on refrigerator states that food must be thrown out after 5 days. Interview with [NAME] N stated that the chicken salad should have been thrown out by 06/02/23. [NAME] N immediately threw it out. [NAME] M stated that food is good for 5-7 days. On 06/20/23 at 8:31 AM, Surveyor interviewed Dietary Manager (DM) O. DM O stated that the dates on containers are when the food was made or opened. [...]

Inspectors wroteBased on observation, interview and record review, the facility did not maintain an infection prevention and control program designed to provide a safe and sanitary environment to help prevent the development and transmission of communicable diseases and infections. Housekeeping staff was observed cleaning public restroom and then going directly to clean resident rooms and going from one resident room to another without changing gloves or performing hand hygiene. This had the potential to affect all residents in the facility. Certified Nursing Assistant (CNA) observed leaving resident (R9) room multiple times to obtain supplies from supply closet without removing Personal Protective Equipment (PPE). The resident was on Enhanced Barrier Precautions (EBP) due to wounds. This had the potential to affect all residents on the Springs Household. [...]

Inspectors wroteBased on record review and interviews, the facility did not implement their abuse policy in regard to screening for 1 of 2 employees that resided out of state. Out of state background check was not completed for [NAME] M.

Inspectors wroteBased on interview and record review, the facility did not develop and implement a comprehensive care plan for 1 of 12 residents reviewed (R3). R3 did not have a care plan for a chronic condition of Pyogenic arthritis. This is evidenced by: R3 was admitted to the facility on [DATE] and has a diagnosis of pyogenic arthritis in left artificial knee joint. This is a chronic bacterial infection requiring prophylactic antibiotic treatment. On 06/20/23 at 2:12 PM, Surveyor reviewed R3's physician orders. Physician orders show that R3 is prescribed Doxycycline Hyclate Oral Tablet 100 MG Give by mouth two times a day for preventative therapy with start date of 04/24/23. On 06/20/23 at 2:30 PM, Surveyor reviewed R3's comprehensive care plan. R3 did not have a care plan for pyogenic arthritis with prophylactic antibiotic treatment. [...]

Inspectors wroteBased on observation, interview and record review, the facility did not review and revise the comprehensive care plans for 2 of 12 sampled residents (R). (R9 and R15) R9's care plan was not updated to identify new open wounds on legs and interventions were not revised to show current treatment for open wounds. R15's care plan was not updated to identify the current plan for resident keeping smoking materials in room and leaving the facility grounds to smoke independently.

Inspectors wroteBased on observation, interview and record review, the facility did not ensure a resident was transferred safely with hoyer (sling) lift to prevent accidents for 1 of 2 residents (R) observed transferred by mechanical lift. (R2) Surveyor observed R2 transferred from bed to chair with a hoyer lift with only one staff person assisting the transfer.

Inspectors wroteBased on observations, interviews and record review, the facility did not ensure that a resident who is fed by enteral means received the appropriate treatment to prevent complications of enteral feeding in 1 resident (R) (R33), of 1 resident observed for cares with a Gastric tube (G-tube). R33 receives enteral feeding by G-tube. Facility staff did not follow the current standard of practice to check G-tube placement prior to administration of enteral feeding.

Inspectors wroteBased on observation and interview, the facility did not ensure residents received insulin safely to meet their needs. Staff administered Lantus insulin to a resident (R) from a vial that was three days beyond the discard date for 1 of 1 insulin injections observed. (R3)