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Health Inspection Summary

Spring Valley Health and Rehab Center

S830 - Westland Dr

Spring Valley, WI 54767

(715) 778-5545

Deficiency Category	Inspection Date: 8/1/24 Complaint Reporting Period: 4/1/24 - 3/31/25	Inspection Date: 6/21/23 Complaint Reporting Period: 4/1/23 - 3/31/24	Inspection Date: 5/4/22 Complaint Reporting Period: 4/1/22 - 3/31/23
Freedom from Abuse, Neglect, and Exploitation Deficiencies	3	2	3
Quality of Life and Care Deficiencies	4	2	2
Infection Control Deficiencies	1	1	2
Resident Assessment and Care Planning Deficiencies	1	2	3
Nursing and Physician Services Deficiencies	2	0	0
Resident Rights Deficiencies	0	0	2
Nutrition and Dietary Deficiencies	1	1	0
Pharmacy Service Deficiencies	1	1	1
Environmental Deficiencies	0	0	0
Administration Deficiencies	2	0	1

Detailed result for inspection on 8/1/24

Date of last standard health inspection:	8/1/24Read the full report (PDF)
Date(s) of complaint inspection(s) between 4/1/24 - 3/31/25	4/25/24Read the full report (PDF)
Date(s) of infection control inspection(s) between 4/1/24 - 3/31/25	No infection control inspections
Total number of Health Deficiencies for this nursing home:	15
Average number of Health Deficiencies in Wisconsin:	9.3
Average number of Health Deficiencies in the United States:	9.6

Freedom from Abuse, Neglect, and Exploitation Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.	4/25/24	4/25/24	4 - Immediate jeopardy to resident health or safety	Few
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.	4/25/24	5/25/24	2 - Minimal harm or potential for actual harm	Few
Respond appropriately to all alleged violations.	4/25/24	5/25/24	2 - Minimal harm or potential for actual harm	Few

Quality of Life and Care Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.	8/1/24	8/29/24	3 - Actual harm	Few
Provide appropriate treatment and care according to orders, resident’s preferences and goals.	8/1/24	8/29/24	2 - Minimal harm or potential for actual harm	Few
Provide appropriate pressure ulcer care and prevent new ulcers from developing.	8/1/24	8/29/24	2 - Minimal harm or potential for actual harm	Few
Provide enough food/fluids to maintain a resident's health.	8/1/24	8/29/24	2 - Minimal harm or potential for actual harm	Few

Infection Control Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Provide and implement an infection prevention and control program.	8/1/24	8/29/24	2 - Minimal harm or potential for actual harm	Many

Resident Assessment and Care Planning Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Provide care by qualified persons according to each resident's written plan of care.	8/1/24	8/29/24	2 - Minimal harm or potential for actual harm	Few

Nursing and Physician Services Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.	4/25/24	5/25/24	2 - Minimal harm or potential for actual harm	Few
Observe each nurse aide's job performance and give regular training.	4/25/24	5/25/24	2 - Minimal harm or potential for actual harm	Many

Resident Rights Deficiencies
No Resident Rights Deficiencies were found during this inspection period.

Nutrition and Dietary Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.	8/1/24	8/29/24	2 - Minimal harm or potential for actual harm	Many

Pharmacy Service Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.	8/1/24	8/29/24	2 - Minimal harm or potential for actual harm	Few

Environmental Deficiencies
No Environmental Deficiencies were found during this inspection period.

Administration Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.	4/25/24	5/25/24	2 - Minimal harm or potential for actual harm	Many
Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.	4/25/24	5/25/24	2 - Minimal harm or potential for actual harm	Many

Detailed result for inspection on 6/21/23

Date of last standard health inspection:	6/21/23Read the full report (PDF)
Date(s) of complaint inspection(s) between 4/1/23 - 3/31/24	7/11/23Read the full report (PDF)
Date(s) of infection control inspection(s) between 4/1/23 - 3/31/24	No infection control inspections
Total number of Health Deficiencies for this nursing home:	9
Average number of Health Deficiencies in Wisconsin:	8
Average number of Health Deficiencies in the United States:	9.4

Freedom from Abuse, Neglect, and Exploitation Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Respond appropriately to all alleged violations.	7/11/23	7/21/23	2 - Minimal harm or potential for actual harm	Few
Develop and implement policies and procedures to prevent abuse, neglect, and theft.	6/21/23	7/21/23	2 - Minimal harm or potential for actual harm	Few

Quality of Life and Care Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.	6/21/23	7/21/23	2 - Minimal harm or potential for actual harm	Few
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.	6/21/23	7/21/23	2 - Minimal harm or potential for actual harm	Few

Infection Control Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Provide and implement an infection prevention and control program.	6/21/23	7/21/23	2 - Minimal harm or potential for actual harm	Some

Resident Assessment and Care Planning Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.	6/21/23	7/21/23	2 - Minimal harm or potential for actual harm	Few
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.	6/21/23	7/21/23	2 - Minimal harm or potential for actual harm	Few

Nursing and Physician Services Deficiencies
No Nursing and Physician Services Deficiencies were found during this inspection period.

Resident Rights Deficiencies
No Resident Rights Deficiencies were found during this inspection period.

Nutrition and Dietary Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.	6/21/23	7/21/23	2 - Minimal harm or potential for actual harm	Some

Pharmacy Service Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.	6/21/23	7/21/23	2 - Minimal harm or potential for actual harm	Few

Environmental Deficiencies
No Environmental Deficiencies were found during this inspection period.

Administration Deficiencies
No Administration Deficiencies were found during this inspection period.

Detailed result for inspection on 5/4/22

Date of last standard health inspection:	5/4/22Read the full report (PDF)
Date(s) of complaint inspection(s) between 4/1/22 - 3/31/23	3/21/23Read the full report (PDF) 6/21/22Read the full report (PDF)
Date(s) of infection control inspection(s) between 4/1/22 - 3/31/23	No infection control inspections
Total number of Health Deficiencies for this nursing home:	14
Average number of Health Deficiencies in Wisconsin:	8.5
Average number of Health Deficiencies in the United States:	8.7

Freedom from Abuse, Neglect, and Exploitation Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Respond appropriately to all alleged violations.	6/21/22	7/18/22	2 - Minimal harm or potential for actual harm	Few
Respond appropriately to all alleged violations.	5/4/22	7/18/22	2 - Minimal harm or potential for actual harm	Few
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.	6/21/22	7/18/22	2 - Minimal harm or potential for actual harm	Few

Quality of Life and Care Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Provide appropriate treatment and care according to orders, resident’s preferences and goals.	6/21/22	7/18/22	4 - Immediate jeopardy to resident health or safety	Few
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.	5/4/22	7/18/22	2 - Minimal harm or potential for actual harm	Few

Infection Control Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Provide and implement an infection prevention and control program.	5/4/22	7/18/22	2 - Minimal harm or potential for actual harm	Many
Ensure staff are vaccinated for COVID-19	5/4/22	7/18/22	2 - Minimal harm or potential for actual harm	Few

Resident Assessment and Care Planning Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.	3/21/23	3/31/23	2 - Minimal harm or potential for actual harm	Few
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.	5/4/22	7/18/22	2 - Minimal harm or potential for actual harm	Few
Ensure each resident receives an accurate assessment.	5/4/22	7/18/22	2 - Minimal harm or potential for actual harm	Few

Nursing and Physician Services Deficiencies
No Nursing and Physician Services Deficiencies were found during this inspection period.

Resident Rights Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.	6/21/22	7/18/22	4 - Immediate jeopardy to resident health or safety	Few
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.	5/4/22	7/18/22	2 - Minimal harm or potential for actual harm	Few

Nutrition and Dietary Deficiencies
No Nutrition and Dietary Deficiencies were found during this inspection period.

Pharmacy Service Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.	5/4/22	7/18/22	2 - Minimal harm or potential for actual harm	Few

Environmental Deficiencies
No Environmental Deficiencies were found during this inspection period.

Administration Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.	6/21/22	7/18/22	4 - Immediate jeopardy to resident health or safety	Few

Complaints and facility-reported incidents in the past 3 years
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.	4/25/24	4/25/24	4 - Immediate jeopardy to resident health or safety	Few
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.	4/25/24	5/25/24	2 - Minimal harm or potential for actual harm	Few
Respond appropriately to all alleged violations.	4/25/24	5/25/24	2 - Minimal harm or potential for actual harm	Few
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.	4/25/24	5/25/24	2 - Minimal harm or potential for actual harm	Few
Observe each nurse aide's job performance and give regular training.	4/25/24	5/25/24	2 - Minimal harm or potential for actual harm	Many
Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.	4/25/24	5/25/24	2 - Minimal harm or potential for actual harm	Many
Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.	4/25/24	5/25/24	2 - Minimal harm or potential for actual harm	Many
Respond appropriately to all alleged violations.	7/11/23	7/21/23	2 - Minimal harm or potential for actual harm	Few
Respond appropriately to all alleged violations.	6/21/22	7/18/22	2 - Minimal harm or potential for actual harm	Few
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.	6/21/22	7/18/22	2 - Minimal harm or potential for actual harm	Few
Provide appropriate treatment and care according to orders, resident’s preferences and goals.	6/21/22	7/18/22	4 - Immediate jeopardy to resident health or safety	Few
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.	3/21/23	3/31/23	2 - Minimal harm or potential for actual harm	Few
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.	6/21/22	7/18/22	4 - Immediate jeopardy to resident health or safety	Few
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.	6/21/22	7/18/22	4 - Immediate jeopardy to resident health or safety	Few

Infection control inspection deficiencies in the past 3 years
This nursing home has not had any infection control inspections in the past 3 years.

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