Spring Valley Care Center

In the surveyor’s words

From the most serious findings on record at Spring Valley Care Center, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF812Dec 18, 2025

  Based 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. […]

• No harm, potential for more than minimal, widespreadF851Nov 21, 2024

  Based 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. Findings include: Review of the Payroll Based Journal (PBJ) [NAME] Report 1705D identified the facility had excessively low weekend staffing during the third quarter of the fiscal year 2024, which included dates between April 1st to June 30th. Review of daily staff schedules and facility staffing report during quarter three indicated adequate levels of staff on weekends. Therefore, the data submitted in the PBJ to CMS was inaccurate. During interview on 11/21/24 at 3:09 p.m. […]

• No harm, potential for more than minimal, patternF880Mar 17, 2022

  Based on observation, interview and document review, the facility failed to follow standard precautions while processing laundry including the use of (PPE) personal protective equipment. The lapses in infection control had the potential to impact all residents who had their laundry washed by the facility. Findings include: During an observation of the soiled laundry area of the facility on 3/15/22, at 7:30 a.m. a laundry aide (LA)-A was observed wearing gloves, mask and eye protection, but was not wearing a protective gown over her personal uniform while sorting soiled personal laundry from three large bins and from an open wired basket used to transport linens to units. LA-A stated she was not trained to wear a gown while sorting soiled laundry. […]

• No harm, potential for more than minimal, isolatedF550Aug 13, 2026

  Based on observation, interview, and document review the facility failed to provide a dignified dining experience for 1 of 1 resident (R9) observed for dignity. Findings include:Findings include:R9's face sheet dated 8/13/26, identified diagnoses of Alzheimer's disease (a progressive brain disorder that slowly destroys memory) and Parkinson's disease (a slow brain disorder that damages nerve cells and makes it hard to control movement).R9's annual Minimum Data Set (MDS) dated [DATE], identified R9 had severe cognitive impairment, had no behaviors, no rejection of cares, needed partial/moderate assistance for eating, and received hospice services. […]

• No harm, potential for more than minimal, isolatedF684Aug 13, 2026

  Based on observation, interview, and document review the facility failed to comprehensively assess and monitor 1 of 1 resident (R7) who exhibited a change in respiratory status.Findings include:Findings include:R7's face sheet dated 8/13/26, identified diagnoses of chronic obstructive pulmonary disease (COPD) and respiratory failure.R7's annual Minimum Data Set (MDS) dated [DATE], identified R7 had intact cognition, had no behaviors, not rejection of cares, was independent in transfers, and was on oxygen therapy. R7's care plan dated 6/2/22, identified R7 was at risk for ineffective airway clearance and infection due to bronchoconstriction, increased mucus, and ineffective cough. R7 had a diagnosis of COPD. Corresponding interventions are as follows:-Administer medications as ordered. […]