Spring Valley Health & Rehabilitation Center

F 0554

locked up from other resident's if the resident was safe to keep their own medications. Complaint numbers 1534273, 1534275, 2585250

Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/25/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Spring Valley Health & Rehabilitation Center

2915 South Fremont Ave Springfield, MO 65804

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0561

During an interview on 08/22/25, at 2:02 P.M., the Unit Manager/LPN said the following:

Level of Harm - Minimal harm or potential for actual harm

-All CNAs can give residents showers. The CNAs should be offering daily to anyone that wants a shower; -The residents should be able to choose whether it’s a shower of bed bath;

Residents Affected - Some -There is a task in the EHR where the staff select when a shower is provided. They should also be completing shower sheets. If the resident refuses, they should note that and offer another day. They should also let the nurse know when the resident refuses; -If the resident is going to an activity, staff should offer a shower later.

During an interview on 08/22/25, at 2:22 P.M., DON said the following: -They do not have a specific shower aide. Any aide can give showers; -The residents should be offered showers at last two times per week. Every room comes with two days for showers. This is provided upon admission; -He/she has a schedule, which is flexible, with certain rooms scheduled on certain days; -Some residents are given a bed bath if therapy makes that suggestion, or the resident prefers a bed bath.

He/she would assume aides are offering a shower.

During an interview on 08/25/25, at 12:30 P.M., the Administrator said the following: -He/she wanted every resident to be happy about getting a shower; -If a resident refused, they would work hard to get them to take one; -Residents should be asked daily if they want a shower; -If residents want two per week, they should be getting them and they should have a choice; -Any nursing staff can give showers. They don’t have a specific shower aide for 400 and 500 halls since the regular aide is out.

Complaint #2572207

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/25/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Spring Valley Health & Rehabilitation Center

2915 South Fremont Ave Springfield, MO 65804

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0584

help much.

Level of Harm - Minimal harm or potential for actual harm

Observation on 08/17/25, at 5:15 P.M., showed the thermostat outside the resident’s room was set to 71 degrees F, but the temperature read 84 degrees F.

Residents Affected - Some

Observation on 08/17/25, at 6:17 P.M., showed the resident’s room temperature measured 84.2 degrees F.

1. 14. Observation on 08/19/25, at 3:07 P.M., showed the private family dining room’s temperature

measured 84.4 degrees F.

2. 15. Review of the Maintenance Director’s weekly temperature logs showed the following:-On

08/08/25, the highest temperature collected for 300 hall was 78 degrees F;-On 08/15/25, the highest temperature obtained for 300 hall was 77 degrees F.

3. 16. During an interview on 08/22/25, at 2:22 P.M., the DON said the following:-She believed by regulation,

building temperatures should be kept below 80 degrees F;-The facility bought ten mini-air conditioners and fans for the residents for half of 300 hall to keep them comfortable;-The air conditioner has been restored.

During an interview on 08/25/25, at 12:30 P.M., Administrator said there had been an issue on the 100 hall with the air conditioner but that air conditioner unit had been replaced. The 300 hall had more than one air conditioner and one of the units had been weaker and it had affected a few of the rooms. There was bid out for the air conditioner to be replaced. There was not an air conditioner on the 200-hall broken. No one had shared with her that 200 hall had been hot. She obtained mini-air conditioners for each resident that was in

the affected area. She was not aware that any residents were too hot. The air conditioner has been restored.

Complaint #1534275, #1534276, #2572207, #2590129, and #2591593

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/25/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Spring Valley Health & Rehabilitation Center

2915 South Fremont Ave Springfield, MO 65804

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0679 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

conversation only lasted about five minutes. There was a log that activities staff document activities attendance including one-to-one visits. He/she opened a 3-ring binder and turned to the resident’s sheet. There was no documentation of visits for the month of August. He/she said he/she forgot to document the dates he/she talked to the resident.

1. 5. During an interview on 08/21/25, at 1:56 P.M., Registered Nurse (RN) EE said the following: -Staff try to

do activities on the SCU, but it is difficult because the residents have attention spans like children;-Activity staff have coffee and conversation, movies, and balloon toss;-He/she did not see any one-on-one activities

on the unit;-He/she thinks there should be more activities on the SCU;

During an interview on 08/22/25, at 8:21 A.M., the Activity Director said the following:-He/she worked at the facility for three weeks;-Activity staff asked the resident's interests upon admission;-Activity staff asked the residents of group and one on one interests;-Activity staff should document activity attendance in the logbook for each hall;-Activity staff should document activity progress notes for residents;-Activity staff did not document on activities other than the activity assessment;-He/she needed to educate the activity staff to document one-on-one activities;-He/she expected activity staff to document one-on-one activities;-The activity program was for quality of life for residents and having something for them to participate in.

During an interview on 08/22/25, at 8:40 A.M., Certified Nurse Aide (CNA) FF said staff did not instruct him/her to provide any one-on-one activities with the residents on the dementia unit.

During an interview on 08/22/25, at 8:42 A.M., Certified Medication Technician (CMT) G said he/she did not observe any one-on-one activities with the residents on the dementia unit. The residents ambulate up and down the halls.

During an interview on 08/22/25, at 9:00 A.M., Activity Staff GG said the following:-Activity staff complete

an activity assessment with the residents;-Activity staff ask what the resident likes to do in their spare time;-Activity staff ask the resident of hobbies, if they like to read;-Activity staff document on the activity assessment and give it to the director who enters the information in the computer;-The care plan coordinator develops the care plan;-Activity staff talk with the residents and family members who reside on

the dementia unit to determine interests;-It is more difficult for one-on-one activity on the dementia unit due to the residents change every five minutes and some did not converse.

During an interview on 08/25/25, at 10:40 A.M., the Director of Nursing (DON) said she expected one-on-one activities on the dementia unit and for staff to document activities provided to residents.

During an interview on 08/25/25, at 12:29 P.M., the Administrator said she expected staff to provide one-on-one and group activities on the SCU. Activities should be provided to all residents, even residents not attending in the activity room.

Complaint 1534276

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/25/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Spring Valley Health & Rehabilitation Center

2915 South Fremont Ave Springfield, MO 65804

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

wound order;-Staff should not wait for the wound doctor to come to the facility and called for a wound order.During an interview on 08/21/25, at 3:07 P.M., the Admissions Director said the following:-He/she entered the orders and completes the assessments upon admission;-On 06/10/25, staff entered the resident's wound orders;-Staff should had started the resident's wound treatment the day of admission or following day.During an interview on 08/22/25, at 11:41 A.M., MDS Coordinator A said he/she said expected staff to document wound treatments. During an interview on 08/22/25, at 11:08 A.M., the resident's nurse practitioner said the following:-The admission Director received the discharge orders from

the hospital for new admissions and the Medical Director adds orders if needed;-If a resident did not have orders from the hospital, staff should notify the physician of what type of wound treatment order is needed;-She did know for sure why wound orders were not entered until 06/13/25 for the resident;-If the resident was admitted from the hospital, she assumes the staff would use those orders;-Staff should document and notify the provider if the resident refused wound care treatments;-She expected staff to document wound treatment as ordered.During an interview on 08/25/25, at 9:25 A.M., the Medical Director said the following:-A resident should come with discharge orders if admitted from a hospital;-He expected staff to notify him if a resident has a significant wound and no wound treatment orders;-He considered a Stage 3 pressure ulcer as significant;-He expected staff to do whatever is appropriate and get the wound doctor involved;-He expected staff to notify him if no orders from the hospital for wound orders; -He expected staff to document on the TAR the admitting wound order and inform him of an admission;-If the resident did not have a wound order from the hospital, staff should notify him for an order before the wound doctor sees the resident.During an interview on 08/21/25, at 12:23 P.M., the Director of Nursing (DON) said

the following:-The resident admitted to the facility on [DATE REDACTED];-The admission director entered the physician orders for new admissions;-Staff should start wound treatments the following day after an admission;-If the resident was admitted on [DATE REDACTED], staff should had called the physician to confirm wound orders and started

the wound treatments the next day. During an interview on 08/25/25, at 12:29 P.M., the Administrator said

the following:-Staff should document wound measurements and a description of a wound upon admission;-She expected staff to notify the physician after the admission was completed;-Staff have up to 24 hours to complete a full assessment;-If the wound doctor is on the way to the facility, staff have him look at a resident's wound but until then, the staff should notify the wound doctor of wound orders;-The wound nurse should observe a resident with a wound after or upon an admission;-She expected staff to document wound treatments on the TAR;-She expected staff to notify the physician if a resident refuses care, wound treatments medications and to document in the progress notes. Complaints 1534271, 2572207, 2590129, 2595498 and 2595716

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/25/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Spring Valley Health & Rehabilitation Center

2915 South Fremont Ave Springfield, MO 65804

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

LPN B said the following:-Staff should monitor urine output and provide catheter every shift and as need for

a resident with a catheter;-Staff should monitor the resident's urine color, amount, and odor, and notify the physician if a resident has issues with their catheter;-Staff should document catheter care on the Treatment Administrator Record (TAR).During an interview on 08/24/25, at 7:20 P.M., Registered Nurse (RN) X said

the following:-Staff should monitor a resident's urine output, color of the urine, and odor;-Staff should notify

the physician if a resident has issues with their catheter and document it in the resident's medical record; -Staff should document catheter care on the TAR.During an interview on 08/22/25, at 11:08 A.M., the Nurse Practitioner said the following:-The resident had a catheter and had consulted with urology when the resident was in the hospital; -The resident had blood in the bag of his/her catheter. The blood was not frank red blood;-The resident wanted her to take the catheter out;-The urologist was aware of the blood in the resident's urine and wanted no changes. During an interview on 08/25/25, at 9:25 A.M., the Medical Director said the following:-Staff should follow protocol for catheter care;-Staff should monitor urine, provide catheter care, and replace the catheter one time per month;-Staff should document catheter care;-Staff should inform him if a resident has any blood in their catheter bag;-Staff should document in the resident's medical record of any blood in the urine and notification of him. During an interview on 08/25/25, at 10:40 A.M., the Director of Nursing (DON) said staff should document if a resident has red or dark urine. During

an interview on 08/25/25, at 12:29 P.M., the Administrator said she expected staff to document the amount of urine output and catheter care of a resident who has a catheter. Complaints 2594499, 2595498, Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/25/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Spring Valley Health & Rehabilitation Center

2915 South Fremont Ave Springfield, MO 65804

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

want a sack lunch, other do not. Some want their meal to be reheated when return. The sack lunch would include deli meat or peanut butter sandwich, fresh fruit and bag chips, along with applesauce or pudding. To ensure all residents get a tray at each meal, each morning, dietary staff gets a census sheet and when they print out the tickets, they go through those to verify all residents are on there. On Thursday, the resident's tray was on the dining room cart. He/she did not know why staff did not take the meal tray to his/her room.During an interview on 08/25/25, at 11:20 A.M., the Director of Nursing (DON) said residents should be provided with meals before dialysis if they want. The nursing staff should let kitchen know and get a sack meal if needed. The resident should be provided with breakfast, and he/she was not aware that he/she did not get breakfast last Thursday. There should be a nutrition assessment with resident preferences. During

an interview on 08/25/25, at 12:30 P.M., the Administrator said residents have to talk to the Dietary Manager to get a meal before leaving for dialysis. There is a nutrition assessment done on admission. Staff should be asking on admission when would like meals in relation to dialysis schedule. The staff should ensure the resident get meal with paper sacks at least. Complaint 2562196

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/25/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Spring Valley Health & Rehabilitation Center

2915 South Fremont Ave Springfield, MO 65804

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755

tablet by mouth one time a day for anemia.

Level of Harm - Minimal harm or potential for actual harm

Review of the resident’s August 2025 MAR showed the following:-On 08/07/25, at 8:00 A.M., staff documented the resident received the ferrous sulfate;-On 08/08/25 through 08/11/25, staff did not document if the ferrous sulfate was given or not given.

Residents Affected - Some

Review of the resident’s POS, current as of 08/11/25, an order, dated 08/07/25, for metoprolol extended-release tablet 25 mg (used to treat high blood pressure, chest pain, and heart failure), give one-half tablet by mouth one time a day for hypertension (high blood pressure). Hold if systolic blood pressure (first/top number of blood pressure) measured 100 millimeters of Mercury (mm/Hg) or less and notify physician if held for three consecutive doses.

Review of the resident’s August 2025 MAR showed the following:-On 08/07/25, at 8:00 A.M., staff documented the resident received he metoprolol with a blood pressure reading of 143/64 mm/Hg;-On 08/08/25 through 08/11/25, staff did not document if the metoprolol was given or not given.

1. 4. During an interview on 08/25/25, at 9:15 A.M., Certified Medication Tech (CMT) AA said staff should

document on the MAR any administered medications.

During an interview on 08/22/25, at 10:00 A.M., CMT D said staff should be documenting medications as administered or not administered with the reason. There should not be blank areas on the MAR.

During an interview on 08/22/25, at 12:30 P.M., CMT A said staff should be documenting medication as administered or not administered with the reason. There should not be blank areas on the MAR.

During an interview on 08/22/25, at 12:40 P.M., RN C said staff should be documenting medication as administered or not administered with the reason. There should not be blank areas on the MAR.

During an interview on 08/25/25, at 11:20 A.M., Director of Nursing (DON) said staff should be documenting medication as administered or not administered with the reason. There should not be blank areas on the MAR. If was not documented it was not done.

During an interview on 08/25/25, at 12:29 P.M., the Administrator said she expected staff to administer resident's medications as ordered and document on the MAR. Staff should be documenting medication as administered or not administered with the reason. There should not be blank areas on the MAR.

Complaints number #1534273, #1534275, #2572207, and #2585250

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

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Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/25/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Spring Valley Health & Rehabilitation Center

2915 South Fremont Ave Springfield, MO 65804

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0759 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

He/she said only brand-new pens were primed and if they were not primed the resident may not receive the correct dose;-The nurse entered the resident’s room and wiped the resident’s abdomen with

an alcohol wipe and administered Humalog.

1. 8. Review of Resident #132’s face sheet showed the following information:-admission date of

08/30/24;-Diagnoses include diabetes.

Review of the resident’s quarterly MDS, dated [DATE REDACTED], showed the resident was cognitively intact.

Review of the resident’s care plan, dated 09/17/24, showed staff to administer medications as order and monitor for side effects and effectiveness.

Review of the resident’s August 2025 POS showed the following orders:-An order, dated 08/29/25, for insulin lispro 100 u/ml, inject 7 units subcutaneously with meals, in addition to the sliding scale;-An order, dated 08/29/25, for insulin lispro 100 u/ml, inject as per sliding scale that follows:-If blood sugar is 0 mg/dL to 119 mg/dL, then do not administer insulin;-If blood sugar is 120 mg/dL to 160 mg/dL, then administer two units of insulin;-If blood sugar is 161 mg/dL to 200 mg/dL, then administer four units of insulin;-If blood sugar is 201 mg/dL to 240 mg/dL, then administer six units of insulin;-If blood sugar is 241 mg/dL to 280 mg/dL, then administer eight units of insulin;-If blood sugar is 281 mg/dL to 320 mg/dL, then administer 11 units of insulin;-If blood sugar is 321 mg/dL or greater, then administer 15 units of insulin and notify the physician if blood sugar is over 400 mg/dL.

Observation on 08/20/25, at 12:24 P.M., showed RN O obtain the resident’s blood sugar at 148 mg/dL. RN O performed hand hygiene, donned gloves, obtained Humalog and drew up nine units of insulin and administered the insulin to the resident. RN O did not prime the needle prior to administering the insulin.

2. 9. During an interview on 08/20/25, at 12:50 P.M., RN O said the following:-Staff do not prime insulin

pens;-The insulin pens have plungers in them, so there is no need to prime the pen;-If there are bubbles seen in the pen, staff should just watch how they position the pen while administering the insulin;-Even if

the resident does get a little bit of air injected, it won't hurt them.

During an interview on 08/22/25, at 10:30 P.M., RN C said he/she was not aware that insulin pens required primed with each use. He/she thought it was just with new pens.

During an interview on 08/22/25, at 10:50 A.M., the DON said all insulin pens are required to be primed each time before insulin is administered. Insulin pens should be primed before each use, every pen, every time. This is manufacturer guidelines. The dose would not be correctly administered if not primed.

During an interview on 08/22/25, at 11:10 A.M., the Administrator said all insulin pens require priming each time.

During an interview on 08/22/25, at 11:20 A.M., Corporate Nurse Consultant said that staff should always prime insulin pens with each use.

Complaint #1534275, #2585250

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/25/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Spring Valley Health & Rehabilitation Center

2915 South Fremont Ave Springfield, MO 65804

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

Observation on 08/20/25, at 12:24 P.M., showed RN O obtain the resident’s blood sugar at 148 mg/dL. RN O performed hand hygiene, donned gloves, obtained Humalog and drew up nine units of insulin and administered the insulin to the resident. RN O did not prime the needle prior to administering the insulin. . During an interview on 08/20/25, at 12:50 P.M., RN O said the following:-Staff do not prime insulin pens;-The insulin pens have plungers in them, so there is no need to prime the pen;-If there are bubbles seen in the pen, staff should just watch how they position the pen while administering the insulin;-Even if

the resident does get a little bit of air injected, it won't hurt them.

During an interview on 08/22/25, at 10:30 P.M., RN C said he/she was not aware that insulin pens required primed with each use. He/she thought it was just with new pens.

During an interview on 08/22/25, at 10:50 A.M., the DON said all insulin pens are required to be primed each time before insulin is administered. Insulin pens should be primed before each use, every pen, every time. This is manufacturer guidelines. The dose would not be correctly administered if not primed.

During an interview on 08/22/25, at 11:10 A.M., the Administrator said all insulin pens require priming each time.

During an interview on 08/22/25, at 11:20 A.M., Corporate Nurse Consultant said that staff should always prime insulin pens with each use.

Complaint #1534275, #2585250

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/25/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Spring Valley Health & Rehabilitation Center

2915 South Fremont Ave Springfield, MO 65804

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many

FORM CMS-2567 (02/99) Previous Versions Obsolete

know of the issues. During an interview on 08/22/25, at 9:05 AM., DA M said the following:-Fans in the walk-in freezer or fridge should be clean and not have black fuzzy stuff, could get into the food. He/she was not sure who cleaned them;-If they have kitchen issues, they let the DM know and she tells maintenance.

During an interview on 08/22/25, at 9:16 A.M., DA N said he/she didn't know who cleaned the fans in the fridge and freezer, but they shouldn't have black stuff on them.During an interview on 08/22/25, at 9:25 A.M., the DM said maintenance cleans the fans in the walk-in fridge and freezer. He/she didn't know how long it had been since they were cleaned. They should not have black fuzzy stuff on them.During an

interview on 08/22/25, at 9:57 A.M., the Administrator said fans in the walk-in fridge and freezer are cleaned by maintenance. They should not have black fuzzy lint on them.5. Observations on 08/17/25, at 3:46 P.M., and on 08/19/25, at 11:29 A.M., showed the following:-Two vents to the right of the steam table

on the ceiling had a fuzzy lint;-A vent over the food prep area on the wall had fuzzy lint on it;-A vent to the right as you enter the kitchen, on the ceiling, near clean dishes, had fuzzy lint.(The lint could fall on food items or food service items.)During an interview on 08/22/25, at 8:50 A.M., DA L said he/she believed maintenance cleaned the vents, he/she didn't know how often or when they were clean last time. Fuzzy lint could fall into the food.During an interview on 08/22/25, at 9:05 AM., DA M said he/she is not sure who cleans vents on walls and ceiling, but fuzzy lint could get into the food.During an interview on 08/22/25, at 9:16 A.M., DA N said he/she didn't know who cleaned the vents, but they shouldn't have lint. During an

interview on 08/22/25, at 9:25 A.M., the DM said vents in the kitchen are cleaned by maintenance. He/she didn't know how often they're cleaned. He/she did not realize they have fuzzy lint on them.During an

interview on 08/22/25 at 3:11 P.M., the Maintenance Director said he/she was responsible for cleaning the vents in the kitchen. He/she cleaned those as needed, but isn't sure how long it had been since they were cleaned. They should not have fuzzy lint on them. During an interview on 08/22/25, at 9:57 A.M., the Administrator said the following:-All vents in the kitchen are cleaned by maintenance. He/she looks at them weeklyThe vents get dirty quickly due to the grease, but they should not have fuzzy lint;-The DM is monitoring the cleaning of the kitchen.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/25/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Spring Valley Health & Rehabilitation Center

2915 South Fremont Ave Springfield, MO 65804

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0908

Keep all essential equipment working safely.

Level of Harm - Minimal harm or potential for actual harm

Based on observation, interview, and record review, the facility failed to maintain equipment in the kitchen in

a safe operating condition when three stove knobs were missing. The facility census was 149.Review showed the facility did not provide a policy regarding upkeep of kitchen appliances.1. Observations on 08/17/25, beginning at 3:46 P.M., and on 08/19/25, at 12:36 P.M., showed the cook stove located in the kitchen had three of the seven burner control knobs missing. During an interview on 08/22/25, at 8:50 A.M., Dietary Aide (DA) L said there are knobs missing. He/she didn't know how long they had been missing.

He/she was still able to turn the stove burners on and off. The Dietary Manager was aware of the knobs missing.During an interview on 08/22/25, at 9:05 AM., DA M said stove knobs were missing, but they were still able to use them as far as he/she knew. If they have kitchen issues, they let the DM know and she tells maintenance. During an interview on 08/22/25, at 9:25 A.M., the DM said he/she was aware there were stove knobs missing. The staff were still able to turn the stove on. He/she needed to order new ones. During

an interview on 08/22/25, at 9:57 A.M., the Administrator said the stove should have all knobs present.

Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/25/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Spring Valley Health & Rehabilitation Center

2915 South Fremont Ave Springfield, MO 65804

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and

the public.

Based on observation, record review, and interview, the facility failed to provide a sanitary environment for all residents and staff when the floors and walls in the kitchen were not kept clean and free of debris. The facility census was 149.Review of the facility's policy titled Nutritional Services Sanitation, dated 03/31/21, showed nutritional services shall ensure a clean and sanitary work environment to promote and protect food safety and to maintain compliance with federal, state and local governing food sanitation and safety.1.

Observations beginning on 08/17/25, at 3:46 P.M., showed the following:-The floors throughout the kitchen had black and white substances in several areas, especially under the sink areas and dishwasher;-There were pieces of food in and around the sink and dishwasher area;-The baseboards in most areas were black with dirt. Observation on 08/17/25, at 3:46 P.M., and on 08/19/25, at 11:29 A.M., showed the following:-The backsplash above the sink to the left when entering the kitchen had a mold looking substance along the section that met the sink, approximately 12 ft. The backsplash had a brown substance on it;-The wall underneath of the sink has large brown splatters in different sections;-The wall under the dishwasher had a black substance present;-The wall behind the stove had grease drops present.During an interview on 08/22/25, at 8:50 A.M., Dietary Aide (DA) L said the floor was swept and mopped each shift, day and evening. The evening cook was supposed to sweep and mop everywhere. The floors should be clean. The walls are cleaned sometimes. Staff have a deep cleaning day two to three times weekly and that is when

the walls are done. During an interview on 08/22/25, at 9:05 AM., DA M said the floors are swept and mopped by whichever staff is working. The walls are more of a deep clean job, and those are done on occasion, he/she doesn't know how often. During an interview on 08/22/25, at 9:16 A.M., DA N said the floors were done by housekeeping. He/she was not sure how often. They should be clean. The walls are done weekly by someone. He/she was not aware of dirty walls or mold.During an interview on 08/22/25, at 9:25 A.M., the Dietary Manager (DM) M said the following:-Floors should be swept and mopped during the day and at night. They also have a deep cleaning where maintenance does a power wash. Housekeeping also buffers the floors three times per week;-He/she wouldn't expect there to not be black stuff and food on

the floors. They should be clean for the most part;-The walls are cleaned by maintenance. There shouldn't be dirt or mold on the walls.During an interview on 08/22/25, at 9:57 A.M., the Administrator said the floors should be clean. The DM is monitoring the cleaning of the kitchen. He/she wasn't aware of mold long the sink where the backsplash meets.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/25/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Spring Valley Health & Rehabilitation Center

2915 South Fremont Ave Springfield, MO 65804

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0925 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

down about 16 inches was completely full of flies;-About four or five live flies flying around the room and eight or nine dead flies laying in the window seal;-The resident said housekeeping cleaned his/her room every other day. He/she doesn’t like for housekeeping to move his/her belongings. Observation and

interview on 08/21/25, at 11:00 A.M., showed the following:-The room has an unpleasant odor, that can could be smelled in the hall;-An empty soda box was under the resident’s bed, clothes were on the floor, and the tables had various items on them, including empty bottles;-The floor appeared dirty with brown places and pieces of food on the floor;-The urinal was fourth of the way full of urine;-The floor had clothes, stuffed animals and soda;-The resident’s dog food bowl had spilled and there was dogfood

in the floor;-About four or five live flies flying around the room and eight or nine dead flies laying in the window seal. During an interview on 08/22/25, at 11:10 A.M., Certified Nurse’s Aide (CNA) I, he/she had noticed some flies in the resident’s room. During an interview on 08/22/25, at 12:22 P.M., Licensed Practical Nurse (LPN) B said he/she had seen flies in and around the resident’s room.

He/she didn’t know how often they spray for flies.

1. 4. Review of Resident #147’s face sheet showed an admission date of 08/07/24.

Review of the resident’s annual comprehensive MDS, dated [DATE REDACTED], showed the resident had severely impaired cognition.

Observation on 08/22/2025, at 1:15 P.M., showed the resident eating lunch in bed. The plate contained cut-up pieces of chicken fried steak, mashed potatoes with gravy, and a sandwich. Beside the plate was an empty ice cream cup. A fly landed on the sandwich twice and continued to fly around the bed and lunch tray. The resident waved his/her hand around to shoo it away several times and said, That's just wrong; go away!

2. 5. During an interview on 08/21/25, at 9:21 A.M., CNA I said he/she had seen flies on the 500 hall. Staff use

fly swatters to kill the flies.

During an interview on 08/21/25, at 1:09 P.M., the Housekeeping Supervisor said housekeepers do their best to get rid of flies. Staff should have a fly swatter to kill the flies as needed.

During interviews on 08/22/25, at 12:50 P.M., and on 08/25/25, at 11:09 A.M., the Maintenance Director said he/she checked the logbooks at the nursing stations every day for staff requests. If only one fly was seen he/she would wait for the monthly pest control service. If more issues were identified he/she would quarantine the room if needed and would notify pest control to schedule services sooner. He/she has not received complaints about flies. He/she has a company that comes at least one time per month, or more often as needed.

During an interview on 08/25/25, at 12:29 P.M., the Administrator said staff address flies with the use of fly baits in drains, contacting the pest control company, making sure the doors get shut faster, and making sure screens in resident rooms are intact. She was not aware of an issue with flies. There is an exterminator that comes in as needed to treat whatever is causing an issue.

Complaint #1534276, #2572207

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet