Springvale Nursing & Rehabilitation Center

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

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

if there was a complicated or serious issue to address. On 8/15/2025 at 11:32 AM, the Director of Nursing was interviewed and stated they began working for the facility approximately 2 months ago and implemented chart auditing to improve staff documentation in the medical records. The licensed nurses, Medical Doctors, and Nurse Practitioners were all responsible for notifying a resident's representative when there were changes in a resident's condition and documenting in the medical record upon communication with the representative. 10 NYCRR 415.3(f)(2)(ii)(c-d)

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

08/15/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Springvale Nursing & Rehabilitation Center

67 Springvale Road Croton on Hudson, NY 10520

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

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

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review conducted during the recertification and abbreviated (NY00359686) survey from 8/11/2025 to 8/15/2025, the facility did not ensure a safe environment with protection of a resident's property from loss or theft. This was evident for 1 (Resident #194) of 6 residents reviewed for personal property. Specifically, Resident #194's personal cell phone went missing and was unable to be found during their stay at the facility. The findings are: The facility policy titled Inventory/Personal Belongings dated 1/2025 documented each resident will be offered/provided a locked drawer or equivalent with a key for small valuables. Resident #194 had diagnoses of cerebral infarction and schizoaffective disorder. The Minimum Data Set 3.0 assessment dated [DATE REDACTED] documented Resident #194 was moderately cognitively impaired. The Social Work Note dated 10/14/2024 documented Resident #194 reported their phone went missing while being charged. The note documented the Director of Social Work discussed the matter with Resident #194's family member. There was no documented evidence Resident #194's cell phone was protected from loss and/or theft in 10/2024. On 8/12/2025 at 11:33 AM, a telephone interview was conducted with the Complainant who stated Resident #194's cell phone and clothing went missing at the facility in 10/2024. There was direct communication with the Administrator regarding the facility's investigation into matter. On 8/14/2025 at 10:15 AM, the Director of Social Work (and Grievance Official) was interviewed and stated they began working for the facility in 7/2024. Clothing brought to the facility was labeled by Housekeeping and documented on an inventory checklist form. A copy of the form was kept on file in the Housekeeping Department and a copy was given to the resident and/or resident's family. The forms were kept at the front desk for easy access to resident families. The Director of Social Work stated, if

a resident lacked capacity, the nursing staff would take possession of a resident's valuables for safekeeping and sometimes gave the valuables to the Director of Social Work for safekeeping. Some residents and their families were adamant about a resident maintaining possession of their valuables, i.e. a cell phone. The Director of SOcial Work stated they were able to offer residents access to their cell phone kept locked in the Social Work Office on a limited basis. The Director of Social Work stated they were unaware whether Resident #194 was offered a personal storage area or lockbox for their cell phone in 10/2024 and would check with the Housekeeping Department for copies of Resident #194's inventory checklists. On 8/15/2025 at 9:32 AM, Licensed Practical Nurse #3 was interviewed and stated some residents had a bedside dresser drawer equipped with a lock for valuables and the Maintenance Department could be contacted to obtain a lockable dresser drawer for residents without one in their room. The residents were able to hold onto the keys for these drawers, or the licensed nurses could hold onto the keys if the residents were unable to do so. On 8/15/2025 at 11:13 AM, the Administrator was interviewed and stated residents were allowed to maintain possession of their cell phones and had their possessions documented on a personal property inventory checklist. The Administrator stated they could not recall the details of Resident #194's missing cell phone. Each resident had access to a lockable dresser drawer in their room to keep their valuables safe. 10 NYCRR 415.29(c)(4)

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

08/15/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Springvale Nursing & Rehabilitation Center

67 Springvale Road Croton on Hudson, NY 10520

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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

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

member followed them and argued with them in the hallway. Registered Nurse Unit Manager #10 advised them (Licensed Practical Nurse #5) to walk away from the family member. They completed a statement and gave it to Registered Nurse Unit Manager #10. They did not remember ever discussing the incident with Administration. During an interview on 08/15/2025 at 10:52 AM, the Director of Nursing stated they were not employed at the facility when Resident #200 was at the facility. They had not had any interaction or conversations with the family member since they started and were not aware of any incidents involving Resident #200 and staff. During an interview on 08/15/2025 at 11:10 AM, the Director of Social Work stated Resident #200's family member did report the incident in question to them involving Licensed Practical Nurse #5. They did not know that the family member felt it was directed at the resident as well. They did discuss the event with the family member, and they thought it was resolved. However, when the family member returned to the facility after Resident #200 passed away, they brought up the incident again and wanted to know what was done about it. They stated they relayed the family member's concern to Administration. They were not certain what happened after that. If there was an allegation of abuse, it should have been reported. During an interview on 08/15/2025 at 11:35 AM, the Administrator stated that

they never received any reports of any incidents between Licensed Practical Nurse #5 and Resident #200 or their family. They should have been notified so they could have investigated the allegation and reported if necessary.10 NYCRR 415.4(b)(2)

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

08/15/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Springvale Nursing & Rehabilitation Center

67 Springvale Road Croton on Hudson, NY 10520

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)

Federal health inspectors cited SPRINGVALE NURSING & REHABILITATION CENTER in CROTON ON HUDSON, NY for a deficiency under regulatory tag F-F0628 during a standard health inspection conducted on 2025-08-15.

Category: Resident Rights Deficiencies

The facility was found deficient in the following area: Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.

Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 15 deficiencies cited during this inspection of SPRINGVALE NURSING & REHABILITATION CENTER.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-10-08.

Federal health inspectors cited SPRINGVALE NURSING & REHABILITATION CENTER in CROTON ON HUDSON, NY for a deficiency under regulatory tag F-F0641 during a standard health inspection conducted on 2025-08-15.

Category: Resident Assessment and Care Planning Deficiencies

The facility was found deficient in the following area: Ensure each resident receives an accurate assessment.

Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 15 deficiencies cited during this inspection of SPRINGVALE NURSING & REHABILITATION CENTER.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-10-08.

Federal health inspectors cited SPRINGVALE NURSING & REHABILITATION CENTER in CROTON ON HUDSON, NY for a deficiency under regulatory tag F-F0657 during a standard health inspection conducted on 2025-08-15.

Category: Resident Assessment and Care Planning Deficiencies

The facility was found deficient in the following area: Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 15 deficiencies cited during this inspection of SPRINGVALE NURSING & REHABILITATION CENTER.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-10-08.

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

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

their stay there. There was a day when another family member called them to report that Resident #200 was covered in feces. They went to the facility to change Resident #200, and the staff were upset that they soiled the sheets in the process. They stated that Resident #200 was dying, and they just wanted them clean and comfortable. During an interview on 08/15/2025 at 9:26 AM, Registered Nurse Unit Manager #2 stated that the certified nurse aides document the care provided for the activities of daily living. If a task was not completed, they should document not performed with a reason. There should not be any omissions

on the certified nurse aide documentation. If it was not documented, it was not done. During an interview on 08/15/2025 at 10:33 AM, Certified Nurse Aide #7 stated that Resident #200 did need to be provided frequent incontinence care. They signed the activities of daily living for all areas including cares not provided with a reason. There should not be any blanks or omissions because if it was not documented it was not done. 10NYCRR 415.12(a)(3)

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

08/15/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Springvale Nursing & Rehabilitation Center

67 Springvale Road Croton on Hudson, NY 10520

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)

Federal health inspectors cited SPRINGVALE NURSING & REHABILITATION CENTER in CROTON ON HUDSON, NY for a deficiency under regulatory tag F-F0695 during a standard health inspection conducted on 2025-08-15.

Category: Quality of Life and Care Deficiencies

The facility was found deficient in the following area: Provide safe and appropriate respiratory care for a resident when needed.

Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 15 deficiencies cited during this inspection of SPRINGVALE NURSING & REHABILITATION CENTER.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-10-08.

Federal health inspectors cited SPRINGVALE NURSING & REHABILITATION CENTER in CROTON ON HUDSON, NY for a deficiency under regulatory tag F-F0761 during a standard health inspection conducted on 2025-08-15.

Category: Pharmacy Service Deficiencies

The facility was found deficient in the following area: Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 15 deficiencies cited during this inspection of SPRINGVALE NURSING & REHABILITATION CENTER.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-10-08.

Federal health inspectors cited SPRINGVALE NURSING & REHABILITATION CENTER in CROTON ON HUDSON, NY for a deficiency under regulatory tag F-F0810 during a standard health inspection conducted on 2025-08-15.

Category: Nutrition and Dietary Deficiencies

The facility was found deficient in the following area: Provide special eating equipment and utensils for residents who need them and appropriate assistance.

Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 15 deficiencies cited during this inspection of SPRINGVALE NURSING & REHABILITATION CENTER.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-10-08.

Federal health inspectors cited SPRINGVALE NURSING & REHABILITATION CENTER in CROTON ON HUDSON, NY for a deficiency under regulatory tag F-F0812 during a standard health inspection conducted on 2025-08-15.

Category: Nutrition and Dietary Deficiencies

The facility was found deficient in the following area: Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Scope/Severity Level E: pattern, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 15 deficiencies cited during this inspection of SPRINGVALE NURSING & REHABILITATION CENTER.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-10-08.

F 0880

gown during the treatment.

Level of Harm - Minimal harm or potential for actual harm

2) During an observation on 08/13/2025 at 12:34 PM, Unit 2 North nursing staff including the registered nurse unit manager, licensed practical nurse, certified nurse aides, and home health aides were serving residents lunch meal without using hand sanitizer, hand sanitizing wipes or hand washing between tray pass and set up among residents. At 12:42 PM Home Health Aide #4 was observed picking up a chair by

the arms to move with bare hands, picked up Resident #6's personal bag from the floor with bare right hand, pushed Resident #183's chair to the table and touched the arm rests with bare hands. Home health aide #4 then sat to feed Resident #183 without washing or sanitizing hands.

Residents Affected - Few

During an interview on 08/13/2025 at 12:55 PM Home Health Aide #4 acknowledged being aware of hand hygiene and removed a small bottle of hand sanitizer from their pocket to show they had sanitizer but shook head no that they did not use it at any time of passing trays or assisting feeding resident #183.

During an interview on 08/14/2025 at 9:05 AM, the Assistant Director of Nursing #2 stated they conducted random audits to check that hand hygiene was completed and provided in-servicing to staff at least quarterly.

During an interview on 08/14/2025 at 11:47 AM, Licensed Practical Nurse #14 stated most staff feeding training was learned as school curriculum. Assistant Director of Nursing #2 provided education on hand hygiene requirements during meals and the Unit Managers monitored to see it was followed.

During an interview on 08/14/2025 at 12:26 PM Registered Nurse Unit Manager #15 stated staff should sanitize hands when passing trays from one table to the next and before assisting a resident with feeding.

They monitored staff for hand hygiene during meal service. 3) During an observation on 8/11/25 at 8:45 AM in the 2 East Dining Room, Home Health Aide #8 was feeding Resident #157. They did not perform hand hygiene when finished, then went to another resident’s tray and touched items to give to that resident. (straw and milk container).

During an interview on 8/11/2025 at 8:50 AM, Home Health Aide # 8 stated they did not perform hand hygiene after feeding the resident, but they did wash their hands in the sink before feeding the resident.

Home Health Aide #8 also stated that they had been trained on infection control.

During an interview on 08/14/2025 at 8:54 AM the Assistant Director of Nursing #2 stated that In-servicing was done with all Home Health Aides on proper hand hygiene with a return demonstration. Assistant Director of Nursing #2 stated that hand hygiene audits were done in the mornings using the annual in-service check list. §415.19(b)(4).

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

08/15/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Springvale Nursing & Rehabilitation Center

67 Springvale Road Croton on Hudson, NY 10520

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 0919

Make sure that a working call system is available in each resident's bathroom and bathing area.

Level of Harm - Minimal harm or potential for actual harm

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review during the recertification and abbreviated surveys (NY00382686) from 8/11/2025-8/15/2025, the facility did not ensure residents were adequately equipped to call for assistance through a communication system that relays the call directly to a staff member or to a centralized staff work area for 1 (Unit 2 East) of 5 residential units. Specifically, on Unit 2 East, the call bell system was not functioning correctly on 8/13/2025, 8/07/2025, 8/01/2025, 5/07/2025, 3/16/2025, 1/11/2025, 1/08/2025, 10/16/2024, 6/19/2024, and 2/22/2024. The findings include:During an interview and observation on 08/13/2025 at 10:44 AM, Certified Nurse Aide #16 stated the audible portion of the Unit 2 East call bell system was not working. Certified Nurse Aide #16 was observed to activate the call bell system from room [ROOM NUMBER]. It was observed that the light illuminated outside the door, but no sound was heard on

the unit floor or at the centralized nurse station.During an interview on 08/13/25 at 11:20 AM, Registered Nurse Unit 2 East Manager stated the call bell system sound was not working. The sound occasionally went out. The staff was to look for call bell lights and give care to the residents. During an interview and

observation on 08/13/2025 at 11:42 AM, Maintenance Worker #11 was observed working on the Unit 2 East call bell system at the nurse's station. They stated the call bell system had no sound coming from system speakers. The light above each room illuminates, the nurses station call bell system monitor indicates a call bell has been activated but no audible sound could be heard. They stated the Unit 2 East call bell system sometime required the computer to be reset to work correctly. The call bell system on Unit 2 East was upgraded to a different system than the rest of the facility several months ago.During an interview and record review on 8/14/2025 at 03:00 PM, the Director of Maintenance stated all maintenance issues for

the facility were entered into The Equipment Lifecycle System (TELS) which was a building management platform designed for senior living communities. Every computer in the facility had the TELS application installed on it and all staff members could enter a maintenance issue into the system. TELS will notify all maintenance staff members that a maintenance issue has been entered. Any call bell system maintenance issue is given a high priority for repair. The Unit 2 East has had call bell system issues in the past. The module for the call bell system was not working correctly and a new call bell system was installed in Unit 2 East in May 2025. The new system required a new monitor and laptop to be installed in the centralized nurse's station. For the 8/14/2025 call bell system maintenance issue, maintenance staff determined that

the speakers located at the centralized nurse's station on Unit 2 East were not working and a new set of speakers were installed. A review of the TELS work order report documents that the call bell system on Unit 2 East was not working correctly and required maintenance on the following days: 8/07/2025, 8/01/2025, 5/07/2025, 1/11/2025, 1/08/2025, 10/16/2024, 6/19/2024, and 2/22/2024. During an interview on 08/15/2025 at 12:46 PM, Assistant Director of Nursing # 2 stated they were not aware of any call bell system sound problem on Unit 2 East. They expected the staff to look for call bell lights that were on and respond as soon as possible. 10 NYCRR 415.29

Residents Affected - Few

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

Event ID:

Facility ID:

If continuation sheet

Federal health inspectors cited SPRINGVALE NURSING & REHABILITATION CENTER in CROTON ON HUDSON, NY for a deficiency under regulatory tag F-F0925 during a standard health inspection conducted on 2025-08-15.

Category: Environmental Deficiencies

The facility was found deficient in the following area: Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.

Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 15 deficiencies cited during this inspection of SPRINGVALE NURSING & REHABILITATION CENTER.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-10-08.

Federal health inspectors cited SPRINGVALE NURSING & REHABILITATION CENTER in CROTON ON HUDSON, NY for a deficiency under regulatory tag F-F0948 during a standard health inspection conducted on 2025-08-15.

Category: Nursing and Physician Services Deficiencies

The facility was found deficient in the following area: Ensure that paid feeding assistants have the training they need.

Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 15 deficiencies cited during this inspection of SPRINGVALE NURSING & REHABILITATION CENTER.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-10-08.