Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens 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 Spring Valley Health And Rehab Center during CMS and state inspections, most recent first.
The facility's abuse, neglect, and exploitation policy referenced Nebraska regulations and contact information instead of Wisconsin's, and this incorrect policy was used for staff training and reporting guidance. The NHA confirmed the error and that the policy was likely intended for another facility, with no other policies used for staff education on this issue.
The facility failed to maintain a safe environment, resulting in falls and injuries for several residents. Two residents suffered major injuries due to falls, with care plans not updated and post-fall assessments not conducted. Other residents also experienced falls without proper interventions. Additionally, wet floors were left without warning signs, and a resident traveled on a busy highway in a power wheelchair without a safety assessment. These deficiencies highlight inadequate supervision and environmental safety measures.
The facility failed to follow food safety and hygiene standards, affecting all residents. Expired and undated food was found in the refrigerator, and food distributed to residents' rooms was uncovered. Staff did not adhere to proper hand hygiene or use hair restraints as required. The Culinary Director acknowledged these practices did not meet facility policies.
The facility failed to establish a comprehensive Infection Control Program, leading to deficiencies such as inadequate water management to prevent Legionella, lack of infection tracking during outbreaks, and improper implementation of Enhanced Barrier Precautions. Staff were observed not following proper PPE protocols, and a nurse did not adhere to infection control practices during wound care. Interviews with staff revealed a lack of oversight and management in infection control practices.
A CNA in an LTC facility was observed applying Nystatin powder to a resident's skin, contrary to the facility's policy that only nurses should administer medications. The resident confirmed this was a common practice, and the CNA admitted to having no formal training. The DON acknowledged that this was against the expected protocol.
A resident with multiple vertebral fractures and a traumatic brain injury did not receive appropriate spinal precautions as per their care plan. Staff failed to perform log rolling during repositioning and did not ensure the resident wore a TLSO brace when the head of the bed was elevated above 30 degrees. Observations showed the resident without the brace and the head of the bed elevated beyond the prescribed limit. The Kardex lacked specific guidance on bed mobility, and the Director of Nursing was unaware of these issues.
Two residents in the facility did not receive adequate pressure ulcer care and prevention. One resident developed and reoccurred pressure injuries on the left heel and toes, with care plans not updated and repositioning not encouraged. Observations showed improper use of pressure-relieving devices. Another resident was admitted with a stage 3 pressure injury, and the facility failed to protect and reposition them adequately, with inconsistent wound assessments. The Director of Nursing acknowledged the lack of proper weekly assessments.
A resident with multiple fractures and a traumatic brain injury experienced significant weight loss due to the facility's failure to monitor and document weight as per physician orders. Despite interventions like health shakes and appetite stimulants, the facility did not weigh the resident weekly, and no weights were recorded from admission. The facility attempted to use Mid Arm Circumference (MAC) as an alternative measure without a formal process. Staff interviews revealed a lack of awareness and understanding of weight monitoring procedures.
The facility failed to document a rationale for the extended use of PRN lorazepam for two residents, beyond the 14-day limit. One resident, with multiple diagnoses including anxiety disorder, had lorazepam administered twice in June without a documented reason for its continued use. Another resident had a PRN order for lorazepam every 2 hours for anxiety, but the facility could not provide adequate documentation to justify the extended use. The DON acknowledged the lack of proper rationale and expected a more detailed explanation from the physician.
An incident involving a cognitively impaired female resident and a male resident with intact cognition highlighted deficiencies in safeguarding measures. The male resident was found in the female resident's room on two occasions, engaging in inappropriate behavior. Despite the female resident's severe cognitive impairment and inability to consent, the facility did not implement immediate safety measures, conduct an investigation, notify the police promptly, or assess the residents' capacity to consent. The female resident had a BIMS score of 3, indicating severe cognitive impairment, while the male resident had a BIMS score of 15, indicating intact cognition. The facility's actions led to a finding of immediate jeopardy due to the significant risk of harm.
The facility did not ensure CNAs received annual performance reviews, affecting four CNAs employed for over a year to more than three years. The Regional Director of Operations confirmed that no yearly performance reviews had been conducted for any employees, potentially impacting all 38 residents.
The facility failed to conduct and document a current facility-wide assessment to determine the necessary resources for resident care during day-to-day operations and emergencies. The provided assessment was outdated, with data from as far back as 2017, and lacked specific information on the current resident population, staff competencies, and other critical factors.
The facility failed to ensure that mandatory staffing data submitted to CMS was complete, accurate, and auditable. The PBJ Staffing Data Reports indicated a lack of 24-hour licensed nursing coverage on specified dates, but facility records showed coverage was present. The data was submitted by the corporate office, and the inaccuracy was confirmed by the Regional Director of Operations.
The facility failed to report allegations of sexual abuse involving two residents to the State Agency and law enforcement within the required timeframe. On two occasions, a CNA found a male resident in compromising situations with a female resident who has severe cognitive impairment. The facility did not assess the ability to consent and did not report the incidents within the mandated 2-hour window.
The facility failed to thoroughly investigate allegations of abuse involving two residents. Despite finding one resident in compromising situations with another cognitively impaired resident on two occasions, the facility did not conduct timely and thorough investigations as required by their policy.
The facility failed to ensure that two CNAs received the required 12 hours of in-service training each year. Despite multiple requests, the facility provided unreadable documentation, making it impossible to verify the training hours. This deficiency has the potential to affect the quality of care for all 38 residents.
Abuse Policy References Incorrect State Regulations
Penalty
Summary
The facility failed to develop and implement an Abuse, Neglect, and Exploitation policy that was compliant with the appropriate state regulations. The policy in use referenced Nebraska reporting regulations and contact information, rather than those for Wisconsin, where the facility is located. This policy was used for staff training and guidance on reporting abuse, neglect, and exploitation, despite the incorrect state references. The Nursing Home Administrator (NHA) confirmed that the policy originated from a management company and was likely intended for a different facility in another state. During interviews, the NHA acknowledged that the facility relied on this incorrect policy and Relias training for staff education regarding abuse and neglect. The surveyor verified that, in practice, self-reports were being made to the correct Wisconsin authorities, but the written policy and training materials did not reflect the correct state requirements. No other policies were identified as being used for staff education on this topic.
Deficiencies in Fall Prevention and Environmental Safety
Penalty
Summary
The facility failed to ensure a safe environment for residents, leading to multiple incidents of falls and injuries. Two residents, identified as R26 and R31, experienced falls resulting in major injuries, including a right shoulder fracture and a compression fracture of the C7 vertebra, respectively. Despite being assessed as at risk for falls, their care plans were not updated with new interventions after previous falls, and post-fall assessments were not conducted. This lack of action contributed to subsequent falls and injuries. Additionally, other residents, including R6 and R2, also experienced falls without proper post-fall assessments or updates to their care plans. R2 had multiple falls over several months, with only one documented interdisciplinary team review and no updated interventions for most incidents. The facility's failure to implement and document appropriate fall prevention strategies placed these residents at risk for further harm. The facility also neglected to address environmental hazards, as observed with wet floors in several residents' rooms without proper signage to warn of the danger. Furthermore, a resident, R14, was allowed to leave the facility and travel on a busy highway in a power wheelchair without a safety assessment or care plan in place. This oversight highlights the facility's inadequate supervision and failure to maintain a safe environment for its residents.
Deficiencies in Food Safety and Hygiene Practices
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, affecting all 33 residents. Observations revealed that expired and undated food items were stored in the refrigerator, contrary to the facility's policy requiring leftovers to be labeled, dated, and discarded within seven days. The Culinary Director acknowledged that opened foods should be dated and discarded after five days, but several items, including diced pineapple, potatoes, pudding, poke cake, ham, and undated lobster meat, were found in the refrigerator past this timeframe. Additionally, food distributed to residents' rooms was not covered, exposing it to potential contamination. The Culinary Director confirmed that food should be covered when transported outside the dining area, but no policy was provided to support this practice. The facility also failed to ensure proper hand hygiene and use of hair restraints among staff. Dietary Aide F was observed serving breakfast with a hair net that did not fully cover their hair, and a CNA was seen preparing a breakfast tray without a hair net. Furthermore, Dietary Aide F was observed handling food with gloves without washing hands before donning them, and subsequently touching various items with the same gloves, leading to potential contamination. The Culinary Director acknowledged that the observed practices did not align with the facility's policies on hand hygiene and glove use.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to establish a comprehensive Infection Control Program, which resulted in several deficiencies affecting both residents and staff. The facility lacked a clear water management process to prevent Legionella transmission, as evidenced by the absence of maintenance records, inspections, or flushing of areas prone to stagnation. The Water Management Plan was not individualized to the facility's water systems and did not include a flow diagram or risk assessment. Additionally, the facility did not have a tracking program for early detection of infections during outbreaks, such as COVID-19 and Norovirus, leading to incomplete and inconsistent surveillance logs. The facility also failed to implement Enhanced Barrier Precautions (EBP) for residents with wounds or indwelling medical devices. Certified Nurse Assistants (CNAs) were observed entering EBP rooms without proper Personal Protective Equipment (PPE) and not sanitizing equipment like Hoyer lifts after use. Furthermore, a Registered Nurse (RN) did not adhere to appropriate infection control practices during wound care, failing to change gloves or perform hand hygiene between tasks, and using contaminated gloves to handle clean supplies. Interviews with facility staff, including the Director of Nursing (DON) and the Infection Control Nurse, revealed a lack of proper infection control management and oversight. The DON acknowledged the deficiencies and attributed them to staff turnover, while the Infection Control Nurse confirmed the failure to follow established policies and procedures. These lapses in infection control practices have the potential to affect all residents in the facility.
Unqualified Staff Administering Medication
Penalty
Summary
The facility failed to ensure that prescription medications were administered by qualified staff, as observed by a surveyor. A Certified Nursing Assistant (CNA) was seen applying Nystatin powder, a prescription antifungal medication, to a resident's abdominal folds and groin area. This action was not in compliance with the facility's policy, which requires that only nurses administer such medications. The resident confirmed that CNAs typically applied the powder when assisting them out of bed, indicating a routine practice that deviated from the expected protocol. The surveyor's review of the resident's medical record revealed a physician's order for the Nystatin powder to be applied topically twice a day to the abdominal folds. However, the CNA involved admitted to having no formal training in administering the medication. The Director of Nursing confirmed that the expectation was for nurses, not CNAs, to administer the Nystatin powder, highlighting a clear breach in protocol and training within the facility.
Failure to Follow Spinal Precautions for Resident
Penalty
Summary
The facility failed to provide appropriate spinal precautions and treatment for a resident, identified as R21, who was admitted with multiple vertebral fractures and a traumatic brain injury. R21's care plan required log rolling for bed mobility and the use of a thoracic-lumbar-sacral orthosis (TLSO) brace when the head of the bed was elevated above 30 degrees. However, observations revealed that staff did not adhere to these precautions. R21 was observed without the TLSO brace while the head of the bed was elevated beyond the prescribed limit, and staff did not perform log rolling during repositioning. Interviews with R21 and staff indicated a lack of compliance with the prescribed spinal precautions. R21 acknowledged not wearing the brace due to discomfort and weight loss, and the brace was found stored improperly in the room. Certified Nurse Assistants (CNAs) were observed repositioning R21 without log rolling, contrary to the care plan and physician orders. Additionally, the Kardex, which staff relied on for care instructions, lacked specific guidance on bed mobility for R21. The Director of Nursing (DON) was unaware of the non-compliance with the head of bed elevation and the absence of log rolling. The DON confirmed that the Kardex should have included the necessary precautions and acknowledged that a nurse had improperly discontinued the TLSO brace without appropriate physician orders. The facility's failure to follow the care plan and physician orders resulted in a deficiency in maintaining R21's highest practicable level of physical well-being.
Inadequate Pressure Ulcer Care and Prevention
Penalty
Summary
The facility failed to provide adequate pressure ulcer care and prevention for two residents, R2 and R187, leading to deficiencies in their treatment. R2 developed pressure injuries on the left heel and right great toe, which reoccurred, and a new pressure injury on the left great toe. The care plan for R2 was not updated since August 2023, and R2 was not repositioned or encouraged for pressure relief as needed. Observations revealed that R2's shoes were on while in a recliner, with no pillow to float the heels, and Podus boots were not applied as required. Additionally, there was a lack of comprehensive documentation and assessment of R2's pressure injuries, and wound care orders were not consistently followed. R187 was admitted with a stage 3 pressure injury to the left posterior thigh. The facility did not ensure proper protection and repositioning for R187, and there were inconsistent assessments of the wounds. Observations showed R187 lying in bed with pressure applied to the buttocks, and scattered open areas were noted on the posterior thighs and buttocks. The documentation lacked comprehensive assessments and updates to the physician regarding the pressure injuries. The Director of Nursing acknowledged that weekly assessments were not completed adequately for R187. The facility's failure to adhere to professional standards of practice for pressure injury care and prevention resulted in inadequate treatment and monitoring of pressure injuries for both residents. The lack of updated care plans, consistent repositioning, and comprehensive documentation contributed to the deficiencies observed by the surveyors.
Failure to Monitor Nutritional Status and Weight Loss
Penalty
Summary
The facility failed to ensure acceptable parameters of nutritional status to maintain the usual body weight for a resident, identified as R21, who was reviewed for nutritional status. R21 was admitted with multiple fractures and a traumatic brain injury, requiring total assistance and being bedbound. Despite physician orders for regular weight monitoring, the facility did not weigh R21 weekly as required, and no weights were recorded from the time of admission until the survey. The lack of weight monitoring led to a significant weight loss that was not appropriately assessed or documented. R21's care plan included interventions for nutrition and hydration, but the facility did not follow through with the necessary documentation and monitoring. The dietician's notes indicated a poor appetite and suggested the use of health shakes and an appetite stimulant, but the facility failed to obtain regular weights to assess the effectiveness of these interventions. The facility attempted to use Mid Arm Circumference (MAC) as an alternative measure of weight status, but there was no formal process or documentation to support this practice. Interviews with staff revealed a lack of awareness and understanding of the procedures for monitoring R21's weight. The Director of Nursing (DON) was unaware of the MAC practice and admitted that the staff had not been properly measuring or documenting R21's weight. The DON also acknowledged that the facility had not weighed R21 at all during the entire stay, highlighting a significant oversight in the care and monitoring of R21's nutritional status.
Failure to Document Rationale for Extended PRN Lorazepam Use
Penalty
Summary
The facility failed to ensure that two residents, identified as R16 and R31, were free from unnecessary medications, specifically regarding the use of lorazepam prescribed on a PRN basis beyond the 14-day limit without documented rationale. R16, who was admitted with diagnoses including chronic obstructive pulmonary disease, heart failure, anxiety disorder, and schizophrenia, had a PRN order for lorazepam starting on 04/04/2024, with an end date of 10/03/2024. The medication was administered twice in June, but there was no documented rationale for its continued use beyond the 14-day limit. A physician's signature was present on a faxed communication from the facility, but it lacked a response or reason for the extended PRN order. Similarly, R31 had a PRN order for lorazepam every 2 hours for anxiety until 12/09/2024. When the surveyor requested a rationale for the extended use, the Director of Nursing (DON) B could only provide a prescription with a diagnosis of anxiety, without further documentation to justify the extended PRN use. During an interview, DON B acknowledged the lack of a proper rationale and stated that they would have expected a more detailed explanation from the physician. This oversight indicates a failure in the facility's medication management practices, particularly in ensuring compliance with regulations regarding the use of psychotropic medications.
Deficiency in Protecting Cognitively Impaired Resident from Sexual Abuse
Penalty
Summary
The report details a concerning deficiency in protecting a resident from sexual abuse within the facility. The incident involved a cognitively impaired female resident (R1) and a male resident (R2) with intact cognition. On two separate occasions, R2 was found in R1's room engaging in inappropriate behavior, including exposing himself and attempting sexual contact with R1. Despite R1's severe cognitive impairment and incapacity to consent, the facility failed to implement immediate safety measures to prevent further abuse. The facility did not conduct an investigation, notify the police promptly, or assess the residents' capacity to consent to a sexual relationship. R1's medical history indicated diagnoses of Alzheimer's disease, disorientation, and depression, with a Brief Interview for Mental Status (BIMS) score of 3 out of 15, indicating severe cognitive impairment. R2, on the other hand, had diagnoses of Parkinson's disease, Alzheimer's disease, and hallucinations, with a BIMS score of 15 out of 15, indicating intact cognition. Despite R1's vulnerability and incapacity to consent, the facility did not take appropriate steps to prevent the sexual abuse from occurring, leading to a finding of immediate jeopardy. The facility's failure to protect residents from sexual abuse not only violated the residents' rights but also created a significant risk of harm. The lack of appropriate interventions, timely notification to authorities, and failure to assess the residents' capacity to consent highlight serious deficiencies in the facility's protection measures. The incidents involving R1 and R2 underscore the critical importance of implementing robust safeguards to prevent abuse and ensure the safety and well-being of all residents, especially those who are cognitively impaired and vulnerable to exploitation.
Lack of Annual Performance Reviews for CNAs
Penalty
Summary
The facility did not ensure Certified Nursing Assistants (CNAs) received a performance review every 12 months for four CNAs reviewed. Specifically, CNA H, CNA M, CNA N, and CNA O did not have documented annual performance reviews despite being employed for periods ranging from over a year to more than three years. On a specific date, a random sample of CNAs was selected for review, and it was found that none of the CNAs had completed annual performance reviews. The Regional Director of Operations confirmed that the facility had not conducted yearly performance reviews for any employees for quite some time. This deficiency had the potential to affect all 38 residents residing in the facility.
Outdated Facility-Wide Assessment
Penalty
Summary
The facility did not conduct and document a facility-wide assessment to determine the necessary resources to care for its residents competently during both day-to-day operations and emergencies. The assessment provided was outdated, with the most recent review dates being February 2022 and March 2023, but the data within the assessment was from as far back as 2017. The assessment included outdated statistics and did not reflect the current census trends, staffing needs, or rehospitalization data. Additionally, the assessment lacked specific information on the current resident population, staff competencies, physical environment, and other critical factors necessary for a comprehensive facility assessment. During an interview, the Regional Director of Operations acknowledged that the provided assessment needed to be updated to a different format. However, the surveyor noted that the current assessment did not reflect the facility's current population or the resources needed to care for the residents. The facility failed to review and update the assessment as necessary and at least annually, which has the potential to affect all 38 residents in the facility.
Inaccurate Staffing Data Submission
Penalty
Summary
The facility did not ensure that mandatory staffing data submitted to CMS for FY Quarter 4, 2023, and FY Quarter 1, 2024, was complete, accurate, and auditable. The Payroll-Based Journal (PBJ) Staffing Data Reports indicated that the facility failed to have licensed nursing coverage 24 hours per day on specified dates. However, upon review, the facility's timecard sheets and daily schedule sheets showed that there was licensed nursing coverage on all the specified dates. The Regional Director of Operations (RDO) confirmed that the data was submitted by someone from the corporate office and acknowledged that the facility had Registered Nurse (RN) coverage on the dates in question. The surveyor was unable to audit the exact documents submitted, leading to the conclusion that the data was inaccurately reported.
Failure to Report Allegations of Sexual Abuse Timely
Penalty
Summary
The facility failed to implement policies and procedures for reporting a reasonable suspicion of a crime in accordance with section 1150B of the Act. Specifically, the facility did not report allegations of sexual abuse involving two residents to the State Agency and law enforcement within the required timeframe. On two separate occasions, a Certified Nursing Assistant (CNA) found Resident 2 in compromising situations with Resident 1, who has severe cognitive impairment. The first incident occurred on 03/28/24, where Resident 2 was found shirtless in Resident 1's bed while Resident 1 was standing without pants. The second incident occurred on 04/01/24, where Resident 2 was found with pants and brief pulled down, exposing his penis, while lying next to Resident 1 in bed. Both incidents were not reported to the State Agency or law enforcement within the mandated 2-hour window. Resident 1, a female with severe cognitive impairment due to Alzheimer's disease, was involved in both incidents. Resident 2, a male with intact cognition but diagnosed with Parkinson's disease and Alzheimer's disease, was found in compromising situations with Resident 1. The Director of Nursing (DON) admitted that the facility did not assess the ability of Resident 1 to consent to the interactions and initially considered the encounters consensual. The facility's failure to report these incidents promptly to the appropriate authorities constitutes a significant deficiency in adhering to mandated reporting requirements.
Failure to Investigate Allegations of Abuse
Penalty
Summary
The facility did not ensure that allegations of abuse involving two residents were thoroughly investigated. On two separate occasions, a Certified Nursing Assistant (CNA) found Resident 2 in compromising situations with Resident 1, who has severe cognitive impairment. On the first occasion, Resident 2 was found shirtless in Resident 1's bed while Resident 1 was standing without pants. On the second occasion, Resident 2 was found with pants and briefs pulled down, exposing his penis, while lying next to Resident 1 in bed. Despite these incidents, the facility did not conduct thorough investigations as required by their policy on abuse, neglect, and exploitation. The facility's Director of Nursing (DON) admitted that the incidents were viewed as consensual without assessing Resident 1's ability to consent, given her severe cognitive impairment. The facility's documentation shows that the families of both residents were informed, but no further action was taken beyond separating the residents and implementing 15-minute checks. The facility failed to interview staff involved in the incidents or take timely and thorough investigative actions to prevent recurrence, thereby not adhering to their own policies and procedures for handling allegations of abuse.
Deficiency in CNA In-Service Training Documentation
Penalty
Summary
The facility did not ensure that two out of five Certified Nursing Assistants (CNA H and CNA N) employed for more than one year received the required minimum of 12 hours of in-service training each year. This deficiency was identified during a survey on 04/25/24, where the surveyor requested in-service training records for CNA H and CNA N. CNA H, hired on 11/16/20, and CNA N, hired on 02/13/23, did not receive the necessary training in communication, behavioral health, and dementia care. The facility provided unreadable documentation, making it impossible to verify the total yearly training hours. Despite multiple requests, the Director of Nursing (DON B) failed to provide clear and readable documentation. This lack of proper training documentation has the potential to affect the quality of care for all 38 residents in the facility. The surveyor informed the Director of Nursing (DON B), Regional Director of Operations (RDO K), and Director of Clinical Operations (DCO L) about the training deficiencies.
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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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Nursing homes near Spring Valley
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Park View Home | 8.3 mi | — | 3 | 0 |
| Baldwin Care Center | 9.8 mi | — | 11 | 0 |
| Ellsworth Health Services | 12.5 mi | — | 0 | 0 |
| Hammond Health Services | 12.9 mi | — | 0 | 0 |
| Plum City Care Ctr | 15 mi | — | 0 | 0 |
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