Not rated by CMS — ratings are suppressed for new or low-volume facilities.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Springvale Nursing & Rehabilitation Center during CMS and state inspections, most recent first.
A resident with cognitive impairment and multiple medical conditions experienced changes in condition, including emesis, IV hydration, antibiotic therapy, and hospital transfer, without documented notification to the resident's representative as required by facility policy. Staff interviews confirmed the responsibility to notify and document, but no evidence of such notification was found in the medical record.
A resident with cognitive impairment reported a missing cell phone that was not protected from loss or theft, despite facility policy requiring secure storage for valuables. Staff interviews revealed inconsistent practices regarding the use of lockable drawers and documentation, and there was no evidence that the resident was offered or provided appropriate safeguards for their property.
The facility did not promptly report suspected abuse, neglect, or theft, nor did it communicate the results of its investigation to the proper authorities as required.
Two residents with significant cognitive and physical impairments did not consistently receive necessary assistance with activities of daily living, as evidenced by numerous omissions in CNA documentation for care, toileting, and dressing. Family members reported finding residents soiled or not properly dressed, and staff confirmed that documentation omissions indicate care was not provided.
Staff failed to follow infection control protocols, including an LPN not wearing a gown during wound care for a resident on enhanced barrier precautions, and home health aides not performing proper hand hygiene between assisting residents during meal service. These actions occurred despite facility policies, physician orders, and staff training on infection prevention requirements.
A call bell system on one unit repeatedly failed to provide audible alerts, requiring staff to rely solely on visual cues to identify when assistance was needed. Despite multiple maintenance interventions and an upgraded system, the issue persisted over several months, with some nursing leadership unaware of the ongoing problem.
A resident with severe cognitive impairment and multiple medical conditions had a Midline IV Catheter inserted after a physician's order, but the resident's representative was not notified of this significant change. Facility staff interviews and record review confirmed that required notification and documentation did not occur, and the representative only learned of the catheter after the resident was hospitalized.
A resident with severe cognitive impairment and behavioral health diagnoses exhibited ongoing aggression, including physical altercations with peers that resulted in serious injuries. Despite repeated incidents and refusal of medications, staff did not adequately evaluate or update the behavioral care plan with new interventions, and documentation of monitoring was lacking. This failure led to unaddressed aggressive behaviors and harm to other residents.
A resident with impaired cognition and behavioral health diagnoses made an allegation of abuse, which was not reported to the state survey agency within the required two-hour timeframe. The incident was reported the following day without a documented time, and there was no evidence that the five-day investigation report was submitted. Staff could not provide confirmation of the required submissions.
A resident with multiple medical conditions alleged rough handling by a CNA. Although facility records and care plans indicated a psychiatric consult was ordered following the incident, there was no documentation that the referral was completed or that the resident was seen by psychiatry. Staff interviews confirmed the consult did not occur, and no explanation was documented for the omission.
The facility failed to ensure their assessment included an evaluation of staff needed to meet residents' needs. The assessment lacked specific staffing minimums and did not include Home Health Aides, despite their presence in the facility. The Administrator was unaware of the requirement to include these details.
Two residents were discharged from an LTC facility without documented discharge care plans or interdisciplinary team meetings. One resident had severe cognitive impairment and required maximal assistance, while the other had intact cognition but needed assistance with daily activities. Despite claims from the social worker that discharge care plans were initiated, no documentation was provided, highlighting a failure in the facility's discharge planning process.
A resident with severe cognitive impairment and a history of falls experienced multiple falls, resulting in a fracture, due to inadequate supervision and lack of timely updates to their fall risk care plan. The facility did not implement necessary interventions after each fall, and staff interviews revealed insufficient measures to prevent further incidents.
Failure to Notify Resident Representative of Change in Condition and Hospital Transfer
Penalty
Summary
The facility failed to notify a resident's representative of significant changes in the resident's condition and treatment, as required by facility policy and state regulations. Specifically, a resident with a history of cerebral infarction and colon neoplasm, who was moderately cognitively impaired, experienced several changes in condition, including episodes of emesis, administration of intravenous hydration and antibiotics, and a transfer to the hospital for evaluation due to a change in mental status. Documentation in the medical record did not show that the resident's representative was informed of the initiation of intravenous hydration, antibiotic therapy, or the transfer to the hospital. Interviews with facility staff, including LPNs, the Medical Director, and the DON, confirmed that it was the responsibility of licensed nurses, nurse practitioners, and medical doctors to notify resident representatives of changes in condition and to document such notifications. However, in this case, there was no evidence in the medical record that the required notifications were made or documented for the resident's representative during these significant events.
Failure to Safeguard Resident's Personal Property
Penalty
Summary
A deficiency was identified when a resident with a history of cerebral infarction and schizoaffective disorder, who was moderately cognitively impaired, reported that their personal cell phone went missing while being charged during their stay. The facility's policy required that each resident be offered a locked drawer or equivalent with a key for small valuables, and that an inventory of personal belongings be maintained. However, there was no documented evidence that the resident's cell phone was protected from loss or theft at the time of the incident. The Social Work note confirmed the missing phone and communication with the resident's family, but did not indicate that appropriate safeguards were in place. Interviews with facility staff revealed inconsistent practices regarding the safeguarding of residents' valuables. The Director of Social Work stated that valuables could be kept in the Social Work Office or in a lockable dresser drawer, but was unaware if the resident had been offered such options. Nursing staff indicated that lockable drawers were available and could be provided by the Maintenance Department if needed, with keys held by either the resident or licensed nurses. The Administrator confirmed that residents' possessions were documented on an inventory checklist and that lockable drawers were available, but could not recall details about the missing cell phone. There was no evidence that the required protections for the resident's property were implemented in this case.
Failure to Timely Report Suspected Abuse, Neglect, or Theft
Penalty
Summary
The facility failed to timely report suspected abuse, neglect, or theft and did not report the results of the investigation to the proper authorities. This deficiency was identified based on the facility's lack of prompt action in notifying the appropriate agencies when an incident of suspected abuse, neglect, or theft occurred. The report indicates that the required notifications and investigation results were not communicated as mandated.
Failure to Provide and Document Required ADL Care for Dependent Residents
Penalty
Summary
The facility failed to ensure that residents who were unable to perform activities of daily living (ADLs) received the necessary care and assistance to maintain good grooming and personal hygiene. For two of seven residents reviewed, documentation by certified nurse aides (CNAs) was inconsistent, with numerous omissions noted in the records for care, toileting, and dressing. One resident with diagnoses including dementia, depression, and anxiety required significant assistance with ADLs, yet CNA documentation showed 135 omissions in one month and 70 omissions the following month. The resident's family reported finding the resident soiled or wet and not dressed in their own clothing during visits. Interviews with staff confirmed that omissions in documentation indicate care was not rendered, and that all care provided or not provided should be documented with a reason. Another resident with cancer, renal insufficiency, and diabetes mellitus also required moderate to maximal assistance with personal hygiene and toileting. CNA documentation for this resident showed 35 omissions over a period of several weeks. Nursing notes documented persistent incontinence and a groin rash, and the resident's family reported having to provide incontinence care themselves, including an incident where the resident was found covered in feces. Staff interviews reiterated that all ADL care must be documented, and omissions suggest the care was not provided. The facility's policy requires that all ADL care be documented by the end of each shift, with reasons provided if care is not performed.
Failure to Adhere to Infection Control Protocols During Resident Care and Meal Service
Penalty
Summary
Surveyors identified that the facility failed to maintain an effective infection prevention and control program, as evidenced by multiple staff not adhering to established protocols. One incident involved a Licensed Practical Nurse who did not wear a gown while providing wound care to a resident on enhanced barrier precautions, despite clear policy and physician orders requiring gown and glove use for high-contact care. The resident in question had severe cognitive impairment, a pressure ulcer, and was under specific orders for enhanced barrier precautions. The nurse acknowledged awareness of the requirement but did not comply during the observed treatment. Additional deficiencies were observed during meal service, where home health aides failed to perform proper hand hygiene between assisting residents. One aide did not sanitize hands after handling various objects and before feeding a resident, while another did not perform hand hygiene after feeding one resident and before assisting another. Staff interviews confirmed knowledge of hand hygiene protocols, and management reported ongoing education and audits, but the observed lapses demonstrated non-compliance with infection control policies.
Failure to Maintain Functioning Call Bell System in Resident Areas
Penalty
Summary
The facility failed to ensure that a functioning call bell system was available in each resident's bathroom and bathing area on Unit 2 East. On multiple occasions, including during the survey, the audible portion of the call bell system was not working, meaning that when the call bell was activated, only a light illuminated outside the resident's room, but no sound was heard on the unit floor or at the centralized nurse station. Staff interviews confirmed that the sound component of the system was intermittently nonfunctional, requiring staff to visually monitor for illuminated call lights rather than being alerted by sound. Maintenance staff confirmed that the speakers at the nurse's station were not working and that the system sometimes required a computer reset to function properly. The call bell system on Unit 2 East had been upgraded to a different system than the rest of the facility several months prior, but issues persisted both before and after the upgrade. A review of maintenance records showed repeated issues with the call bell system on Unit 2 East over several months, with multiple work orders documenting malfunctions on specific dates. Despite the high priority assigned to call bell repairs, the problem recurred, and some nursing leadership were unaware of the ongoing sound issues. The expectation from some staff was to look for call bell lights and respond as soon as possible, but the lack of an audible alert compromised the intended function of the call system.
Failure to Notify Resident Representative of Midline Catheter Insertion
Penalty
Summary
A deficiency occurred when the facility failed to immediately notify a resident's representative of a significant change in the resident's physical status, specifically the insertion of a Midline Intravenous Catheter. The facility's policy required notification of the resident, attending physician, and representative in the event of a change in condition or status. The resident involved had diagnoses including dementia, end stage renal disease, and coronary artery disease, and was assessed as having severely impaired cognition and requiring moderate to maximal assistance with activities of daily living. A physician ordered the placement of a Midline Catheter, and an external intravenous contracting company inserted the catheter. However, there was no documentation in the nursing progress notes or elsewhere that the resident's representative was notified of this procedure. Interviews with facility staff revealed that the Registered Nurse Manager did not recall if the representative was notified, and the Assistant Director of Nursing confirmed that notification and documentation should have occurred. The resident's representative stated they were unaware of the catheter placement until seeing the resident in the hospital. The Nurse Practitioner also indicated an expectation that the Unit Manager would notify the representative, but there was no evidence this occurred. The lack of notification and documentation was confirmed through record review and interviews.
Failure to Evaluate and Update Care Plan Following Resident Aggression
Penalty
Summary
A deficiency was identified when the facility failed to ensure that a resident with a history of dementia, anxiety disorder, and psychotic disorder remained free from abuse and that care plan interventions were evaluated for effectiveness. The resident exhibited ongoing aggressive behaviors, including agitation, yelling, refusal of medications, and physical aggression toward other residents and staff. Despite these behaviors, there was no documented evidence that the care plan was reviewed or updated with new interventions following incidents of aggression. On multiple occasions, the resident refused prescribed medications and displayed escalating behaviors, such as screaming, attempting to hit others, and pouring water on the floor. Staff documented these behaviors and attempted verbal redirection and de-escalation, but these interventions were largely unsuccessful. The care plan was only minimally updated to include medication administration and notification of the physician, but there was no evidence of a comprehensive evaluation or adjustment of interventions to address the resident's ongoing aggression. Two significant incidents occurred where the resident physically contacted other residents, resulting in injury. In one event, the resident propelled their wheelchair into another resident, and in another, the resident struck a peer, causing a fall that led to a head hematoma, wrist fracture, and hip fracture. Interviews with staff confirmed that the behavioral care plan had not been updated with new interventions after these incidents, and monitoring documentation was missing. The lack of timely and effective evaluation of care plan interventions contributed to the failure to protect residents from abuse and neglect.
Failure to Timely Report Alleged Abuse and Submit Investigation Documentation
Penalty
Summary
The facility failed to ensure that an allegation of abuse was reported to the state survey agency within the required timeframe for one resident. Specifically, a resident with a history of bipolar disorder, paranoid schizophrenia, and schizoaffective disorder, who had moderately impaired cognition and behavioral issues, made a serious accusation of being beaten and raped. The resident called 911, prompting a response from law enforcement and paramedics, and was subsequently transferred to the hospital for evaluation. The hospital examination found no evidence of trauma, but noted a bizarre thought process and referred the resident for telepsychiatry evaluation. Despite the gravity of the allegation, the facility did not report the incident to the Department of Health within the mandated two-hour window. Documentation indicated the report was made the following day, with no specific time recorded. Additionally, there was no documented evidence that the required five-day investigation report was submitted to the Department of Health. Interviews with facility staff revealed that the Director of Nursing, who was responsible for reporting and is no longer employed at the facility, may have submitted the report, but no confirmation or documentation could be provided.
Failure to Complete Psychiatric Referral Following Abuse Allegation
Penalty
Summary
A deficiency occurred when a resident with multiple diagnoses, including status post fall with right elbow injury, alcoholic cirrhosis, and hypertension, made an allegation of abuse involving rough handling by a Certified Nursing Assistant. Following the incident, facility documentation—including the Accident and Incident report, nursing notes, and care plans—indicated that a referral for psychiatric consultation was made as per the physician's order and the resident's care plan, which required psychiatric consults as needed. However, there was no documented evidence that the psychiatric referral was completed or that the consultation took place after the incident. Interviews with facility staff and the psychiatric nurse practitioner confirmed that no psychiatric consult was performed for the resident following the abuse allegation, despite expectations and documented interventions requiring such a referral. The psychiatric nurse practitioner stated they had only seen the resident once prior to the incident and did not receive a referral after the event. Other staff members, including the LPN Unit Manager and DON, were unable to provide a reason for the lack of follow-through, and documentation did not clarify why the psychiatric consultation was not completed as ordered.
Deficiency in Facility Staffing Assessment
Penalty
Summary
The facility was cited for not ensuring that their facility assessment included an evaluation of the overall number of staff needed to meet each resident's needs. The Facility Assessment, last updated on October 10, 2024, included a section on staffing plans based on an average daily census of 185 residents. However, this section did not specify any actual staffing minimum numbers. During an interview, the Staffing Coordinator outlined the staffing requirements for different shifts, but these details were not reflected in the Facility Assessment. Additionally, the Administrator acknowledged the challenge of maintaining adequate staffing levels due to a state of emergency regarding the healthcare worker shortage in New York. The Administrator also mentioned the presence of Home Health Aides in the facility, but these aides were not included in the Facility Assessment or staffing assignments. The Administrator admitted to being unaware that the Facility Assessment needed to indicate minimum staffing levels or include Home Health Aides.
Plan Of Correction
Plan of Correction: Approved January 17, 2025 What corrective action(s) will be accomplished for those residents found to have been affected by the practice? The facility reviewed and updated Facility Assessment to include HHA, PAR level, and Minimum PAR levels. The IDT met to review the assessment to ensure sufficient staffing for all units in the facility. How will you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken? The facility acknowledges that all residents have the potential to be affected by this practice. The staffing coordinator will maintain the daily unit staffing sheet (RN, LPN, CNA, and HHA) of all units for sufficient staffing. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur? The staffing coordinator will review and update the daily unit staffing sheet to include HHAs on the unit staffing sheet. The staffing coordinator will be responsible for maintaining the daily unit staffing sheet to be presented to the Director of Nursing. A random audit of the daily staffing sheet will be conducted by the Director of Nursing times weekly x 4 weeks, then monthly x 3 months. How will the corrective action(s) be monitored to ensure the deficient practice will not recur? What quality assurance program will be put into practice? The Director of Nursing audit findings will be presented monthly and quarterly to the Quality Assurance and Improvement Committee. The facility will meet 100% compliance with such audit. All audits will be brought to QAPI monthly x 3 months. Completion Date: 1/16/25 Responsible person(s): Director of Nursing.
Failure to Initiate Discharge Care Plans for Residents
Penalty
Summary
The facility failed to ensure comprehensive care plans with measurable objectives and timeframes were developed for residents' medical, nursing, and psychosocial needs, as identified in their comprehensive assessments or discharge plans. Specifically, two residents were discharged without having discharge care plans initiated upon admission. Resident #2, who had severe cognitive impairment, muscle weakness, and required maximal assistance with daily activities, was discharged without a documented discharge care plan or an interdisciplinary team meeting prior to discharge. Additionally, there were no documented interventions for the resident's incontinence and skin integrity issues. Resident #4, who had intact cognition but required assistance with daily activities, was also discharged without a documented discharge care plan or an interdisciplinary team meeting. The resident received a Notice of Medicare Non-Coverage and chose not to appeal, leading to a discharge without the necessary planning. The social worker claimed that discharge care plans were initiated, but no documentation was provided to support this claim. Interviews with the Director of Nursing and the social worker revealed discrepancies in the discharge planning process. The Director of Nursing stated that discharge care plan meetings are conducted with the interdisciplinary team, while the social worker mentioned that discharge care plans are initiated upon admission. However, the social worker was unable to provide copies of the care plans for the two residents in question, indicating a failure in the facility's discharge planning process.
Failure to Prevent Falls and Update Care Plans
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards and did not provide adequate supervision and assistance devices to prevent accidents for three residents reviewed for accidents. Specifically, one resident with a history of falls experienced multiple falls within a short period, resulting in an acute left femoral neck fracture. The facility did not document timely updates or interventions after each fall to prevent recurrence, and the resident's fall risk care plan was not updated with new interventions. The resident, who was admitted with diagnoses including dementia, Alzheimer's disease, and chronic pain, had severe cognitive impairment and required maximal assistance for daily activities. Despite being at high risk for falls and exhibiting poor balance, the resident's care plan lacked specific interventions to address these risks. The facility's policy required a fall risk evaluation and consistent intervention after falls, but these were not adequately implemented. Interviews with staff revealed that the resident did not have side rails due to cognitive limitations and that interventions to engage the resident outside their room were implemented only after multiple falls. The facility administrator acknowledged that a new protocol for post-fall intervention was instituted after the resident's falls, indicating a lack of effective measures in place at the time of the incidents.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| New York State Veterans Home At Montrose | 0.8 mi | — | 4 | 0 |
| Sky View Rehabilitation & Health Care Center L L C | 1.5 mi | — | 6 | 0 |
| Northern Riverview Health Care, Inc | 3.3 mi | — | 23 | 0 |
| Helen Hayes Hospital R H C F | 3.7 mi | — | 0 | 0 |
| Helen Hayes Hospital T C U | 3.7 mi | — | 0 | 0 |
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