Original Inspection report

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265188

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

SPRING VALLEY HEALTH & REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

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 0550

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Honor the resident’s right to a dignified existence, self-determination, communication,
and to exercise his or her rights.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation and interview, the facility failed to ensure staff provided care in a
manner that promoted dignity when staff failed to ensure one resident’s (Resident #92)
catheter bag (tube placed to drain the bladder into an external collection bag) was kept
covered. A sample of 32 residents was sampled in a facility with a census was 142.
1. Record review of Resident #92’s face sheet (basic patient information) showed the
following information:
-admitted to the facility 3/13/19;
-[DIAGNOSES REDACTED].
Record review of the resident’s care plan, dated 3/15/19, showed the following
information:
-Has a [MEDICAL CONDITION] related to history of [MEDICAL CONDITION];
-Has an indwelling catheter related to [MEDICAL CONDITION].
Record review of the resident’s (MONTH) 2019 physician order [REDACTED].
-Maintain Foley catheter with size 16 French/10 cubic centiliter (cc) balloon for [MEDICAL
CONDITION]; change as needed for obstruction;
-An order dated 3/13/19, for indwelling catheter care every shift;
-An order dated 4/18/19, to change Foley catheter monthly for infection for prevention.
Observation on 4/29/19, at 2:51 P.M., showed the resident rested in bed. The resident’s
catheter collection bag was not inside a dignity bag and hung on an outside bed rail
facing the open doorway with collected urine visible from the hallway.
Observation on 5/6/19, beginning at 3:17 P.M., showed the resident lay in bed. The
resident’s catheter collection bag did not rest inside a dignity bag and hung on a lower
bed rail facing the open doorway, with collected urine visible from the hallway. Licensed
Practical Nurse (LPN) O and Certified Medication Tech (CMT) N performed personal hygiene,
catheter care, and changed the sheet and bed pad for the resident, moving the catheter bag
as needed. After repositioning the resident onto his/her back, CMT N re-hung the catheter
bag on a lower bed rail, not inside a dignity bag, facing the doorway with urine visible
from the hallway.
During an interview on 5/7/19, at 11:05 A.M., CNA P said catheter bags should be placed
inside a dignity bag and hung below the resident’s bladder for proper drainage. The bag
should not be hung facing the doorway without a dignity bag.
During an interview on 5/7/19, at 3:16 P.M., the Director of Nursing (DON) said all
catheter bags should be placed inside a dignity bag, either under their wheelchair or on a
lower bed rail. The bag should not be hung facing the doorway with collected urine visible
from the doorway.

F 0558

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Reasonably accommodate the needs and preferences of each resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview, and record review, the facility failed to place a call
light within reach for one resident (Resident #236) who was dependent on staff for cares.
A sample of 32 residents were selected for review in a facility with a census of 142.
1. Review of Resident #236’s admission record (face sheet) showed the facility admitted

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265188

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

SPRING VALLEY HEALTH & REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

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 0558

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 1)
the resident on 4/11/19 from the hospital.
Record review of the resident’s care plan, dated 4/11/19, showed the following:
-Resident has an activities of daily living (ADL – dressing, grooming, bathing, eating,
and toileting) self-care performance deficit related to [MEDICAL CONDITION] (paralysis of
one side of the body) and stroke diagnoses;
-Ensure the resident’s call light is within reach and encourage the resident to use the
call bell to call for assistance;
-Resident has a communication problem related to [MEDICAL CONDITION] (an impairment of
language, affecting the production or comprehension of speech and the ability to read or
write);
-Staff to anticipate and meet needs;
-Resident is able to nod head yes or no.
Record review of the resident’s fall scale, dated 4/11/19, showed the resident is a high
fall risk.
Record review of the resident’s admission nurse note dated 4/12/19, at 9:11 A.M., showed
the following:
-Late entry for 4/11/19 at 11:40 P.M.;
-Resident arrived from the hospital;
-admission orders [REDACTED]
-Resident is non-verbal, but is able to follow conversation and make needs known by
nodding or shaking head.
Record review of the resident’s admission minimum data set (MDS – a federally mandated
comprehensive assessment tool), dated 4/18/19, showed the following:
-Severe cognitive impairment;
-Disorganized thinking, behavior present, fluctuates (comes and goes);
-Required extensive assistance of two or more staff with bed mobility;
-Required extensive assistance of one staff with transfers, dressing, eating, toileting,
and personal hygiene;
-Total dependence on staff for bathing assistance;
-Functional limitation in range of motion, upper extremity and lower extremity impairment
on one side;
-[DIAGNOSES REDACTED].
-Receives physical therapy (PT), occupational therapy (OT), and speech therapy (ST), five
times per week each.
Observation on 4/24/19, at 3:15 P.M., showed the resident lay on the bed in his/her room,
and the resident’s call light lay in the middle of the room on the resident’s floor, out
of the resident’s reach.
Observation on 4/26/19, at 10:50 A.M., showed the resident lay on the bed in his/her room,
and the resident’s call light lay in the middle of the room on the resident’s floor, out
of the resident’s reach.
Observation on 4/30/19, at 12:40 P.M., showed the following:
-The resident lay on the bed, he/she asked surveyor for assistance in getting out of bed
for lunch;
-The resident’s call light lay across a table located approximately 18 inches away from
the resident’s bed on the resident’s immobile right side, out of reach of the resident’s
left hand.
Observation on 5/02/19, at 12:15 P.M., showed the following:
-The resident alone in his/her room, laying on the bed with the tray table across the bed
with a lunch plate on the tray;
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265188

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

SPRING VALLEY HEALTH & REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

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 0558

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 2)
-The resident’s drinks were out of his/her reach.
-The resident’s call light was connected to the bed frame below the level of the mattress
on the right side, out of the resident’s sight and reach.
During an interview on 5/07/19, at 11:05 P.M., the Director of Nursing (DON) said all
staff should ensure the resident’s call light is in the resident’s reach before leaving
the resident’s room.
MO 938

F 0561

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Honor the resident’s right to and the facility must promote and facilitate resident
self-determination through support of resident choice.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to provide showers/baths per
care plan and/or resident’s preference for three residents (Resident#19, #42, #73) out of
a selected sample of 32 residents. The facility census was 142.
Record review showed the facility did not provide a policy regarding showers
1. Record review of Resident #19’s face sheet (a document that gives a resident’s
information at a quick glance) showed the following information:
-Original admission date of [DATE];
-[DIAGNOSES REDACTED].
Record review of the resident’s care plan, dated 11/02/18, showed the following:
-Resident has activities of daily living (ADL – dressing, grooming, bathing, eating, and
toileting) self-care deficit related to weakness and failure to thrive;
-Resident will receive assistance necessary to meet ADL needs;
-Assist with daily hygiene, grooming, dressing, oral care, and eating as needed.
Record review of the resident’s quarterly Minimum Data Set (MDS), a federally mandated
assessment instrument completed by facility staff, dated 01/23/19, showed the following
information:
-Cognitively intact;
-Extensive assistance with bed mobility, transfers, dressing, toilet use, personal
hygiene;
-Physical help with bathing, one person assist.
Record review of the resident’s (MONTH) 2019 shower sheets showed the resident received a
shower/bed bath on 02/01/19, 02/08/19, 02/15/19, 02/21/19, and 02/27/19.
Record review of the resident’s (MONTH) 2019 shower sheets showed the following the
resident received a shower/bed bath on 03/06/19, 03/13/19, 03/22/19, and 03/27/19.
Record review of the resident’s (MONTH) 2019 shower sheets showed the following:
-Resident received a shower/bed bath on 04/05/19, 04/12/19, and 04/24/19;
-Not applicable was marked on 04/09/19, 04/16/19, 04/18/19, 04/19/19, 04/20/19, and
04/25/19.
Record review of the resident’s shower sheets from 05/01/19 to 05/03/19, did not show any
showers/bed baths complete.
During an interview on 05/01/19, at 4:00 P.M., the resident said he/she has not had a
shower in seven days. The shower aide is always too busy. He/she wants to receive a shower
regularly, as he/she feels dirty.
2. Record review of Resident #42’s face sheet showed the following information:

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265188

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

SPRING VALLEY HEALTH & REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 3)
-Original admission date of [DATE];
-[DIAGNOSES REDACTED]. This leads to a limitation of the flow of air to and from the lungs
causing shortness of breath).
Record review of the resident’s care plan, dated 12/21/18, showed the following:
-Resident has activities of daily living self-care deficit as evidenced by need for
extensive assist at times related to disease process, [MEDICAL CONDITION];
-Resident will receive assistance necessary to meet ADL needs;
-Assist to bath/shower as needed. Daughter-in-law to give shower due to his refusal to
allow staff to give shower;
-Assist with daily hygiene, grooming, dressing, oral care, and eating as needed;
-The focus, goal, and interventions were initiated on 11/16/17.
Record review of the resident’s quarterly MDS, dated [DATE], showed the following
information:
-Moderate cognitive impairment;
-Supervision with bed mobility, transfers, dressing, toilet use, and personal hygiene;
-Total dependence with bathing, one person assist.
Record review of the resident’s (MONTH) 2019 shower sheets showed the following
information:
-Resident received a shower/bed bath on 02/06/19, 02/13/19, 02/20/19, and 02/27/19.
Record review of the resident’s (MONTH) 2019 shower sheets for (MONTH) 2019 showed the
following:
-Resident received a shower/bed bath on 03/06/19, 03/13/19, and 03/28/19.
Record review of the resident’s (MONTH) 2019 shower sheets for (MONTH) 2019 showed the
following:
-Resident received a shower/bed bath on 04/10/19;
-Resident refused a shower on 04/13/19;
-Not applicable was marked on 04/12/19, 04/18/19, 04/19/19, 04/20/19, and 04/25/19.
Record review of the resident’s shower sheets from 05/01/19 to 05/03/19, did not show any
showers/bed baths complete.
During an interview on 04/29/19, at 3:15 P.M., the resident’s responsible party (RP) said
the resident is not receiving regular showers. He/she said at one time her daughter-in-law
would assist due to the facility not bathing the resident regularly.
3. Record review of Resident #73’s face sheet showed the following information:
-Readmission date of [DATE];
-[DIAGNOSES REDACTED].
Record review of the resident’s (MONTH) 2019 shower sheets showed the following the
resident received a shower/bed bath on 02/06/19, 02/13/19, 02/20/19, and 02/27/19.
Record review of the resident’s (MONTH) 2019 shower sheets showed the following the
resident received a shower/bed bath on 03/06/19, 03/11/19, 03/13/19, and 03/27/19.
Record review of the resident’s quarterly MDS, dated [DATE], showed the following
information:
-Severe cognitive impairment;
-Extensive assistance with bed mobility, transfers, dressing, toilet use, personal
hygiene;
-Bathing, activity did not occur during this period.
Record review of the resident’s care plan, dated 03/24/19, showed the following:
-Resident has ADL self-care deficit related to weakness and impaired mobility;
-Resident will receive assistance necessary to meet ADL needs;
-Assist with daily hygiene, grooming, dressing, oral care, and eating as needed.
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265188

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

SPRING VALLEY HEALTH & REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 4)
Record review of the resident’s shower sheets for (MONTH) 2019 showed the following:
-Resident received a shower/bed bath on 04/10/19 and 04/24/19;
-Resident refused a shower on 04/13/19;
-Not applicable was marked on 04/12/19, 04/18/19, 04/19/19, and 04/25/19.
Record review of the resident’s shower sheets, dated from 05/01/19 to 05/03/19, did not
show any showers/bed baths complete.
During an interview on 04/26/19, at 9:32 A.M., the resident said he/she has not been
receiving two baths a week since being discharged from hospice in (MONTH) 2019. She would
like to have at least two showers a week.
4. During an interview on 05/03/19, at 12:45 P.M., Certified Nurse Aide (CNA) C said
he/she assists with showers/bed baths of the 200 hall. He/she is able to complete all
his/her baths. He/she will get pulled to the floor, and is currently the only aide on the
200 hall, and will also be assisting with showers. He/she does not mark not applicable on
the electronic shower log. He/she does not regularly have residents that refuse showers.
Sometimes residents will request their shower at a different time.
5. During an interview on 05/06/19, at 1:18 P.M., CNA J said he/she assists with showers
on the 100 hall. He/she normally does not get pulled to the floor, and will sometimes
assist staff on other halls with showers. He/she is able to complete all his/her showers.
If he/she is unable to, he/she will complete the next day. He/she was marking not
applicable on the electronic shower log if a resident received a shower the day before and
did not want one on their regularly scheduled day. Management staff have advised for staff
not to select the not applicable option.
6. During an interview on 05/06/19, at 3:08 P.M., Registered Nurse (RN) D said residents
should receive two showers a week and as needed. The residents have had complaints about
not getting their showers. Most days the shower aides are able to keep up, however they do
have to occasionally have to pull a shower aide to the floor. He/she tracks the shower
sheets. The shower aide brings the shower sheets to RN D at the end of day. Staff should
be completing 12 showers a day. Not applicable should not be marked on the electronic
shower sheet. He/she is unsure why staff mark that option. An in-service training has been
held to advise staff not to mark that option.
7. During an interview on 05/07/19, 9:35 A.M., RN K said shower aides should check
resident’s finger nails and trim their nails, if they are not diabetic. Activity staff
should also be checking nails when they are painting nails.
8. During an interview on 05/07/19, at 3:19 P.M., the Director of Nursing (DON) said
residents should be receiving two showers/bed baths per week. RN D monitors the shower
sheets for the front of the facility and RN K monitors the shower sheets for the back of
the facility. There is always a shower aide assigned to the hall, and CNA’s can also
assist with bathing. He/she is unsure with staff select the not applicable option on the
electronic show sheet.
MO 975, MO 963, MO 041 and MO 486

F 0584

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

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.

Based on observation, interview, and record review, the facility failed to provide a

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265188

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

SPRING VALLEY HEALTH & REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 5)
clean, orderly, homelike environment for when one resident’s (Resident #57) room was not
kept clean; when strong urine odors were present on 100 hall; when staff did not clean the
dining room in a timely fashion; and when left over trays and lids were stacked on the
tables of four residents (Resident #48, #52, #79, and #123). The facility had a census of
142.
1. During an interview on 04/25/19, at 4:05 P.M., with eight members of the resident
council, the residents said they were unhappy with the housekeeping. The facility has
smells throughout the facility, specifically the 100 and 500 resident halls. Trash cans
are not being changed and bathrooms are not being cleaned. The residents have to tell the
facility staff to clean the bathrooms. The dining room is not cleaned up on Saturdays and
activities are being done without the dining room being cleaned from previous meals.
2. Observation on 4/24/19, at 9:25 A.M., showed a strong urine odor in the common area
between the 100 hall entrance and the nurses’ station.
Observation on 5/3/19, at 11:40 A.M., showed a strong urine odor on the 100 hall toward a
sunroom throughout the length of the hall. At that time, a resident made a face and said,
This hall always stinks really bad!
Observation on 5/6/19, at 7:25 A.M., showed a strong urine odor in the common area between
the 100 hall entrance and the nurses’ station.
3. Observation of Resident #57’s room on 04/25/19, at 10:51 A.M., showed the following:
-Privacy curtain drawn, several dried blood stains the size of a dime covering a two feet
by two feet area;
-Fecal matter on the wall behind the toilet and on the toilet tank around the handle;
-Two scratches on the wall, above resident’s bed, approximately 6 to 12 inches long and 6
inches wide.
During an interview on 04/25/19, at 10:51 A.M., the resident said the blood stain on the
curtain is from at least two months ago. The nurse is aware of the stains and has advised
the head housekeeper. He/she said housekeeping staff do not clean the bathroom very good,
as he/she has pointed out the fecal matter behind the wall and on the toilet. He/she was
advised by housekeeping staff that they clean it the best they can.
Observation of the resident’s room on 05/02/19, at 11:05 A.M., showed the following:
-Privacy curtain drawn, several dried blood stains the size of a dime covering a two feet
by two feet area;
-Fecal matter on the wall behind the toilet and on the toilet tank around the handle;
-Two scratches on the wall, above resident’s bed, approximately 6 to 12 inches long and 6
inches wide.
Observation of the resident’s room on 05/03/19, at 11:26 A.M., showed the following:
-Privacy curtain drawn, several dried blood stains the size of a dime covering a two feet
by two feet area;
-Fecal matter on the wall behind the toilet and on the toilet tank around the handle;
-Two scratches on the wall, above resident’s bed, approximately 6 to 12 inches long and 6
inches wide.
Observation of the resident’s room on 05/07/19, at 10:16 A.M., showed the following:
-Privacy curtain drawn, several dried blood stains the size of a dime covering a two feet
by two feet area;
-Small amount of fecal matter on the wall behind the toilet and on the toilet tank around
the handle;
-Two scratches on the wall, above resident’s bed, approximately 6 to 12 inches long and 6
inches wide.
During an interview on 05/03/19, at 10:12 A.M., Housekeeping (HK) H said he/she cleans
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265188

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

SPRING VALLEY HEALTH & REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 6)
rooms every day. If a door is closed, he/she knocks, and if the resident is not in there
he/she will enter the room and clean. No residents on the 200 hall refuse room cleanings,
as they all like their rooms cleaned. He/she cleans the bathrooms daily, and will wipe
down the toilet and faucets. He/she said maintenance is responsible for removing soiled
curtains. He/she will report if a curtain is soiled and needs to be replaced. Deep
cleanings are conducted when someone moves out, if someone dies, or as needed. A deep
cleaning consists of spraying down the whole room with cleaner, including the bed, TV,
walls, and bathroom.
During an interview on 05/06/19, at 10:51 A.M., Certified Medication Tech (CMT) A said
he/she will advise housekeeping if something in room is dirty, like a privacy curtain or
floors.
During an interview on 05/06/19, at 11:41 A.M., the Housekeeping Supervisor (HS) said
housekeeping cleans rooms daily. They will sweep and mop floor, clean bathrooms, and will
clean toilet and surrounding areas. If a privacy curtain in a room is dirty, housekeeping
will write down on a board in housekeeping area and he/she or maintenance will change.
He/she said the curtains are changed as needed.
During an interview on 05/06/19, at 11:43 A.M., HK I said when he/she cleans rooms he/she
empties the trash, sweeps and mops floor, and will clean the toilet. If he/she observes a
privacy curtain to be soiled, he/she will take it down.
During an interview on 05/06/19, at 1:15 P.M., the Maintenance Supervisor said
housekeeping or maintenance will change out resident privacy curtains. He/she said
housekeeping has a schedule and changes all curtains periodically.
During an interview on 05/07/19, at 3:19 P.M., the Administrator said resident rooms
should be cleaned daily and privacy curtains should be changed as needed. He/she said it
is all of staff’s responsibility; housekeeping, maintenance, nursing staff, to regularly
observe a resident’s room to ensure proper cleanliness.
4. Record review of the Meal Service Schedule showed the following:
-Lunch service in the East Dining room is at 12:55 P.M.;
-Lunch service in the West Dining room is at 12:15 P.M.;
-Dinner service in the East Dining room is at 5:55 P.M.,;
-Dinner service in the West Dining room is at 5:15 P.M.
Observations of the west dining room on 04/25/19, at 5:00 P.M., showed the following:
-A large spill, which looked like milk, underneath a table;
-Green beans underneath three tables;
-Two tables that had white drink spatters on the legs.
Observations of the east dining room on 04/25/19, at 5:00 P.M., showed the following:
-Several pieces of paper/trash on floor;
-A large spill of a clear liquid.
Observations of the west dining room on 05/02/19, at 3:02 P.M., showed the following:
-Mashed potatoes on the floor;
-Brown clumps resembling gravy on the floor;
-The table legs of five tables had visibly dirt and white liquid splatters. The legs
appeared to be sticky.
During an interview on 05/03/19, at 1:14 P.M., HK H said the HS will advise housekeeping
staff as to who is responsible for cleaning dining rooms that day. He/she normally cleans
the dining room, which consists of wiping down legs of tables. He/she said kitchen staff
cleans tops of tables and maintenance cleans the floors.
During an interview on 05/06/19, at 11:41 A.M., HS said he/she assigns staff to clean the
dining room daily. The dining rooms should be cleaned up between meals. Housekeeping staff
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265188

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

SPRING VALLEY HEALTH & REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 7)
sweeps the floors and cleans the table legs. Maintenance runs the floor cleaning machine
and dietary staff cleans off the table tops. If there is a spill, housekeeping staff cover
the spill with an absorbent pad and then will spot clean spill.
During an interview on 05/06/19, at 1:15 P.M., MS said he cleans dining room floors on
Mondays and the floor tech cleans the dining room floors on the other days. The dining
room floors need to be cleaned after breakfast before activities. Either dietary staff or
the floor tech will sweep the floors as needed. Dietary staff will clean the chairs and
tables.
5. Observation on 05/01/19, at 1:23 P.M., showed Resident #123 sitting at a four top table
by him/herself with approximately 11 trays stacked on his/her table.
Observation on 05/02/19, at 1:30 P.M., showed Resident #48 and #79 were sitting at four
top table. Staff placed nine trays and four lids on their table while they were eating.
Observation on 05/03/19, at 2:08 P.M., showed Resident #123 sitting at a four top table
with nine trays and nine lids stacked up in front of where he/she is eating.
Observation on 05/06/19, at 1:28 P.M., showed Resident #52 sitting at a four top table
with ten trays and ten lids stacked on his/her table while he/she was eating.
During an interview on 05/07/19, at 8:27 A.M., Registered Nurse (RN) D said staff should
not stack lids or trays on a tables where residents are eating.
During an interview on 05/07/19, at 3:19 P.M., the Director of Nursing (DON) said staff
should not stack trays or lids on a table while residents are eating. If the resident sits
down at a table where trays and lids are already stacked, staff should remove the items.
MO 834, MO 938, MO 975, MO 041 and MO 486

F 0600

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Protect each resident from all types of abuse such as physical, mental, sexual abuse,
physical punishment, and neglect by anybody.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview, and record review, the facility failed to protect one
resident (Resident # 70) from verbal abuse when Licensed Practical Nurse (LPN) X yelled
loudly at the resident and made threat of possible harm of resident to other staff
members. Additional staff members overheard the yelling and did not take steps to protect
the resident. A sample of 32 residents were selected for review. The facility census was
142.
Record review of the facility Abuse and Neglect Prevention Policy and Procedure, revised
on (MONTH) (YEAR), showed the following:
-Purpose to establish guidelines that prevents, identifies and report resident abuse and
neglect;
-All residents have the right to be free from abuse, neglect, misappropriation of resident
property, exploitation, corporal punishment, involuntary seclusion, and any physical or
chemical restraint not required to treat the resident’s medical symptoms. This includes
prohibiting nursing facility staff from taking or using photographs or recordings in any
manner that would demean or humiliate a resident, and prohibits using any type of
equipment (e.g., cameras, smart phones, and other electronic devices) to take, keep, or
distribute photographs and/or recordings on social media or through multimedia messages.
Residents must not be subjected to abuse by anyone, including, but not limited to,

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265188

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

SPRING VALLEY HEALTH & REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

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 0600

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 8)
facility staff, other residents, consultants or volunteers, staff of other agencies
serving the resident, family members or legal guardians, friends, or other individuals;
-Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or
punishment with resulting physical harm, pain or mental anguish. This also includes the
deprivation by an individual, including a caretaker, of goods or services that are
necessary to attain or maintain physical, mental, and psychosocial well-being. Instances
of abuse of all residents, irrespective of any mental or physical condition, cause
physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical
abuse, and mental abuse including abuse facilitated or enabled through the use of
technology;
-Verbal abuse is defined as the use of oral, written or gestured language that willfully
includes disparaging and derogatory terms to residents or their families, or within their
hearing distance, regardless of their age, ability to comprehend, or disability. Examples
of verbal abuse include but are not limited to: threats of harm, saying things to frighten
a resident such as telling a Resident that he/she will never be able to see his/her family
again;
-Mental abuse includes, but is not limited to, humiliation, harassment, threats of
punishment or deprivation ;
-Residents must not be subjected to abuse by anyone, including, but not limited to,
facility staff, other residents, consultants or volunteers, staff of other agencies
serving the resident, family members or legal guardians, friends, or other individuals;
-All allegations of resident abuse, neglect, exploitation, mistreatment, injuries of
unknown origin and misappropriation should be reported immediately to the charge nurse.
The charge nurse is responsible for immediately reporting the allegations of abuse to the
administrator, or designated representative;
-Should an incident or suspected incident of resident abuse (as defined above) be reported
or observed, the administrator or his/her designee will designate a member of management
to investigate the alleged incident;
-The administrator or designee will complete documentation of the allegation;
-Upon receiving a report of an allegation of resident abuse, neglect, exploitation or
mistreatment, the facility shall immediately implement measures to prevent further
potential abuse of residents from occurring while the facility investigation is in
process. If this involves an allegation of abuse by an employee, this will be accomplished
by separating the employee accused of abuse from all residents through the following or a
combination of the following, if practicable: (1) suspending the employee; and/or (2)
segregating the employee by moving the employee to an area of the facility where there
will be no contact with any residents of the facility;
-Following completion of the facility investigation, if the facility concludes that the
allegations of resident abuse are unfounded, the employee will be allowed to return to job
duties involving resident contact.
1. Record review of the Resident #70’s admission Minimum Data Set (MDS – a federally
mandated assessment tool completed by facility staff), dated 3/14/19, showed the
following:
-admitted to the facility on [DATE] from the hospital;
-Resident is cognitively intact;
-Resident exhibited no problem behaviors;
-Resident has [DIAGNOSES REDACTED].
-Resident takes scheduled and as needed (PRN) pain medications;
-Resident experiences frequent pain that makes sleep difficult;
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265188

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

SPRING VALLEY HEALTH & REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

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 0600

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 9)
-Resident rates pain as a ‘5’ (on a scale of 0=no pain to 10=most severe pain).
During an interview on 4/26/19, at 11:30 A.M., the resident said the following:
-On 4/25/19 at approximately 7:30 P.M., the resident woke up after falling asleep in
his/her chair;
-The resident was in pain and woke up whimpering;
-The resident told Certified Nurse Aide (CNA) Y to let Licensed Practical Nurse (LPN) X
know that he/she was in pain;
-CNA Y returned and said he/she spoke to LPN X and the nurse said the resident could not
have any more pain medication;
-The resident said he/she then turned on his/her call light and waited approximately 30-45
minutes for staff to answer the call light;
-At approximately 9:30 P.M., LPN X came to the resident’s room and at that point the
resident said he/she needed to go the bathroom;
-After the resident was assisted to the bathroom,LPN X came in with the resident’s other
routine medications and the resident attempted to talk to the nurse about his/her need for
pain medication;
-The nurse responded by telling the resident he/she had already received his/her pain
medications and there was nothing the nurse could do about it;
-The nurse then said she was not going to discuss the matter and turned away and walked
out of the resident’s room;
-The resident said he/she called out to the nurse that she could call the physician and
the nurse hollered back that she had already done that;
-The resident said he/she then placed a call to his/her family member to discuss the
issue;
-The resident said while trying to have a private conversation with his/her family member
about the issue, the nurse came back into the room and stood, listening to the
conversation;
-The resident then told the nurse to get out of his/her room and the nurse waved and
slammed the resident’s door;
-The resident said it is known by the staff that he/she does not like to have his/her door
closed;
-The resident said he/she then began yelling at the nurse to open the door and the nurse
returned and told the resident he/she needed to be quiet;
-This angered the resident and he/she began yelling at and cursing the nurse, the nurse
then began to yell back at the resident;
-The resident said he/she believed other residents and staff heard the yelling;
-The resident said no other staff intervened while the nurse yelled at the resident.
The allegation of possible abuse was reported to the Director of Nursing (DON) on 4/26/19,
at approximately 12:15 P.M.
During an interview on 4/26/19, at 3:33 P.M., the DON said the following:
-The resident said he/she was angry with LPN X and the LPN pulled the resident’s door shut
hard and yelled at the resident;
-The resident reported the nurse walked out of the room;
-The nurse reported a few minutes later, the nurse re-entered the room while the resident
was on the phone and tried to listen in on the resident’s private phone conversation;
-The resident said he/she did not report the incident to anyone.
During an interview on 4/26/19, at 11:53 P.M., Certified Nurse Aide (CNA) Y said the
following;
-He/she worked on the night the resident had problems with LPN X;
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265188

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

SPRING VALLEY HEALTH & REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

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 0600

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 10)
-The CNA said that night, he/she heard LPN X yelling at the resident from up at the
nurses’ station while the nurse was halfway down the hall;
-The nurse then came to the nurse’s station and said the resident was being a b word and
the nurse said she needed to go vape before she knocked the resident out;
-The CNA said there were at least two other staff at the desk at the time;
-The CNA did not report the incident to administration;
-The CNA did not intervene or attempt to stop the staff member from yelling at the
resident.
During an interview on 4/27/19, at 12:37 A.M., CNA Z said the following:
-LPN X was very angry and yelling at the resident;
-The nurse was calling the resident names and cursing about the resident at the nurse’s
desk;
-The nurse said while at the desk, if he/she did not go vape, she was going to slap the
resident in the face;
-The CNA said he/she did not report the incident, but there were other staff that
overheard the nurse’s comments;
-The CNA did not intervene or attempt to stop the staff member from yelling at the
resident.
During an interview on 5/06/19, at 3:55 P.M., RN K said the following:
-From now on if resident makes an allegation of abuse or neglect, staff are supposed to
report immediately to the RN supervisor/unit manager or the administrator;
-The facility has two hours to report the allegation to DHSS.
During an interview on 5/07/19, at 11:05 A.M., the DON said the CNAs who overheard LPN X
yelling and cursing about the resident, should have intervened and reported the incident
immediately.
During an interview on 5/07/19 at 3:15 P.M., the administrator said the following:
-Staff should report all allegations of resident abuse or neglect immediately to the
administrator;
-The alleged staff should be immediately suspended pending the completion of the
investigation;
-The administrator is the facility abuse coordinator.
During an interview on 5/07/19 at 3:15 P.M., the facility administrator said the
following:
-All allegations of abuse/neglect should be reported immediately to the abuse/coordinator
which is the administrator;
-Any staff member accused of or observed abusing a resident should be immediately
suspended, pending the result of the investigation.
MO 318, MO 364, MO 384, MO 417 and MO 587

F 0609

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Timely report suspected abuse, neglect, or theft and report the results of the
investigation to proper authorities.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview, and record review, the facility staff failed to report an
allegation of abuse timely to management and the Survey Agency when staff heard Licensed
Practical Nurse X yelling at one resident (Resident # 70). A sample of 32 residents were

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265188

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

SPRING VALLEY HEALTH & REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

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 0609

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 11)
selected for review. The facility census was 142.
Record review of the facility Abuse and Neglect Prevention Policy and Procedure, revised
on (MONTH) (YEAR), showed the following:
-Purpose of the is to establish guidelines that prevents, identifies and report resident
abuse and neglect;
-Policy is for all residents have the right to be free from abuse, neglect,
misappropriation of resident property, exploitation, corporal punishment, involuntary
seclusion, and any physical or chemical restraint not required to treat the resident’s
medical symptoms. This includes prohibiting nursing facility staff from taking or using
photographs or recordings in any manner that would demean or humiliate a resident, and
prohibits using any type of equipment (e.g., cameras, smart phones, and other electronic
devices) to take, keep, or distribute photographs and/or recordings on social media or
through multimedia messages. Residents must not be subjected to abuse by anyone,
including, but not limited to, facility staff, other residents, consultants or volunteers,
staff of other agencies serving the resident, family members or legal guardians, friends,
or other individuals;
-Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or
punishment with resulting physical harm, pain or mental anguish. This also includes the
deprivation by an individual, including a caretaker, of goods or services that are
necessary to attain or maintain physical, mental, and psychosocial well-being. Instances
of abuse of all residents, irrespective of any mental or physical condition, cause
physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical
abuse, and mental abuse including abuse facilitated or enabled through the use of
technology;
-Verbal abuse is defined as the use of oral, written or gestured language that willfully
includes disparaging and derogatory terms to residents or their families, or within their
hearing distance, regardless of their age, ability to comprehend, or disability. Examples
of verbal abuse include but are not limited to: threats of harm, saying things to frighten
a Resident such as telling a resident that he/she will never be able to see his/her family
again;
-Mental abuse includes, but is not limited to, humiliation, harassment, threats of
punishment or deprivation;
-All allegations of resident abuse, neglect, exploitation, mistreatment, injuries of
unknown origin and misappropriation should be reported immediately to the charge nurse.
The charge nurse is responsible for immediately reporting the allegations of abuse to the
Administrator, or designated representative;
-All allegations of Resident abuse, neglect, exploitation, mistreatment, injuries of
unknown origin and misappropriation shall be reported to the state survey agency, not
later than two (2) hours after the allegation is made, if the events that cause the
allegation involve abuse or result in serious bodily injury, or not later than twenty-four
(24) hours if the events that cause the allegation do not involve abuse and do not result
in serious bodily injury.
-A report shall be made by calling or emailing the survey agency as they have defined to
do.
1. Record review of the Resident #70’s admission MDS, dated [DATE], showed the following:
-admitted to the facility on [DATE] from the hospital;
-Resident is cognitively intact;
-Resident exhibited no problem behaviors;
-Resident has [DIAGNOSES REDACTED].
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265188

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

SPRING VALLEY HEALTH & REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

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 0609

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 12)
-Resident takes scheduled and as needed (PRN) pain medications;
-Resident experiences frequent pain that makes sleep difficult.
During an interview on 4/26/19, at 11:30 A.M., the resident said the following:
-On 4/25/19 at approximately 7:30 P.M., he/she woke up after falling asleep in my chair;
-The resident was in pain and woke up whimpering;
-The resident told Certified Nurse Aide (CNA) Y to let Licensed Practical Nurse (LPN) X
know that he/she was in pain;
-The CNA Y returned and said she spoke to the nurse LPN X and the nurse said the resident
could not have any more pain medication;
-The resident said he/she then turned on his/her call light and waited approximately 30 to
45 minutes for staff to answer the call light;
-At approximately 9:30 P.M., LPN X came to the resident’s room and at that point the
resident said he/she needed to go the bathroom;
-After the resident was assisted to the bathroom the LPN X came in with the resident’s
other routine medications and the resident attempted to talk to the nurse about his/her
need for pain medication;
-The nurse responded by telling the resident he/she had already received his/her pain
medications and there was nothing the nurse could do about it;
-The nurse then said she was not going to discuss the matter and turned away and walked
out of the resident’s room;
-The resident said he/she called out to the nurse that she could call the physician and
the nurse hollered back that she had already done that;
-The resident said he/she then placed a call to his/her family member to discuss the
issue;
-The resident said while trying to have a private conversation with his/her family member
about the issue, the nurse came back into the room and stood, listening to the
conversation;
-The resident then told the nurse to get out of his/her room and the nurse waved and
slammed the resident’s door;
-The resident said it is known by the staff that he/she does not like to have his/her door
closed;
-The resident said he/she then began yelling at the nurse to open the door and the nurse
returned and told the resident he/she needed to be quiet;
-This angered the resident and he/she began yelling at and cursing the nurse, the nurse
then began to yell back at the resident;
-The resident said he/she believed other residents and staff heard the yelling.
During an interview on 4/26/19, at 3:33 P.M., the Director of Nursing (DON) said the
following:
-The resident said he/she was angry with LPN X and the LPN pulled the resident’s door shut
hard and yelled at the resident;
-The resident reported the nurse walked out of the room;
-The nurse reported a few minutes later, the nurse re-entered the room while the resident
was on the phone and tried to listen in on the resident’s private phone conversation;
-The resident said he/she did not report the incident to anyone.
During an interview on 4/26/19, at 11:53 P.M., CNA Y said the following;
-He/she worked on the night the resident had problems with LPN X;
-The CNA said that night, he/she heard LPN X yelling at the resident from up at the
nurse’s station while the nurse was halfway down the hall;
-The nurse then came to the nurse’s station and said the resident was being a b word and
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265188

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

SPRING VALLEY HEALTH & REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

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 0609

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 13)
the nurse said she needed to go vape before she knocked the resident out;
-The CNA said there were at least two other staff at the desk at the time;
-The CNA did not report the incident to administration.
During an interview on 4/27/19, at 12:37 A.M., CNA Z said the following:
-LPN X was very angry and yelling at the resident;
The nurse was calling the resident names and cursing about the resident at the nurse’s
desk;
-The nurse said while at the desk, if he/she did not go vape, she was going to slap the
resident in the face;
-The CNA said he/she did not report the incident, but there were other staff that
overheard the nurse’s comments.
During an interview on 5/06/19, at 3:55 P.M., Registered Nurse (RN) K said the following:
-From now on if resident makes an allegation of abuse or neglect, staff are supposed to
report immediately to the RN supervisor/unit manager or the administrator;
-The facility has two hours to report the allegation to Department of Health and Senior
Services (DHSS).
During an interview on 5/07/19, at 11:05 A.M., the DON said the following:
-The CNAs who overheard LPN X yelling and cursing about the resident, should have reported
immediately.
-All allegation of abuse and neglect must be reported to DHSS within 2 hours.
During an interview on 5/07/19 at 3:15 P.M., the administrator said the following:
-Staff should report all allegations of resident abuse or neglect immediately to the
administrator;
-The administrator is the facility abuse coordinator.

F 0656

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Develop and implement a complete care plan that meets all the resident’s needs, with
timetables and actions that can be measured.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, record review and interviews, the facility failed to develop and
implement comprehensive care plans inclusive of wounds for one resident (Resident #92) and
toileting needs for one resident (Resident #5). Staff documented conflicting information
for one resident’s (Resident #57) care plan. A sample of 32 residents was selected for
review. The facility was 142.
Record review of the facility’s policy entitled Comprehensive Person Centered Care Plan,
last reviewed 1/24/19, showed the following:
-Each resident will have a person centered plan of care to identify problems,
needs,strengths, preferences, and goals that will identify how the interdisciplinary team
will provide care;
-For each problem, need, or strength a resident-centered measurable goal is developed;
-Staff approaches are to be developed for each problem/strength/need; assigned disciplines
will be identified to carry out the intervention.
1. Record review of Resident #92’s face sheet (basic patient information) showed the
following information:
-admitted to the facility 3/13/19;
-Admitting [DIAGNOSES REDACTED]. The admitting [DIAGNOSES REDACTED].

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265188

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

SPRING VALLEY HEALTH & REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

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 0656

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 14)
Observation on 4/29/19, at 2:48 P.M., showed the resident sat in a wheelchair in his/her
room. His/her left great toe appeared black from the tip to the toenail. The resident’s
left heel and foot were wrapped in gauze.
Record review of the resident’s (MONTH) 2019 physician order [REDACTED].
Record review of the resident’s (MONTH) 2019 Treatment Administration Record showed staff
documented completion of left heel wound treatment daily as ordered.
Record review of the resident’s current care plan, dated 3/15/19, showed staff did not
document information pertaining to a wound on the left heel or the left great toe.
2. Record review of Resident #57’s face sheet (a document that gives a resident’s
information at a quick glance) showed the following:
-admitted to the facility on [DATE];
-The resident’s [DIAGNOSES REDACTED].
Record review of resident’s nurse’s note dated 11/24/18, at 2:03 A.M., showed staff spoke
to resident about leaving the facility. The resident said he/she had gone to the emergency
room because he/she was feeling out of control and did not know what else to do. Staff
discussed if resident has overwhelming emotions again and feels out of control to notify
staff in order to help. Resident understood and agreed.
Record review of resident’s nurse’s note dated 11/24/18, at 8:58 A.M., showed staff
interviewed the resident at this time in regard to leaving facility and feeling out of
control. The resident said he/she gets nervous and feels like they are going to explode so
he/she just walks. Staff explained they would like to help and the resident needs to let
staff know how they are feeling.
Record review of the resident’s social service note dated 11/24/18, at 9:18 P.M., showed
staff educated resident on the facility leave of absence policy.
Record review of resident’s care plan, dated 11/24/18, showed the following:
-Resident has habit of signing self out and leaving facility;
-He/she likes to walk when he becomes stressed. He/she usually walks to nearby store or
will walk to Walmart;
-Resident will be able to leave as desired to stress relief without event;
-Encourage resident to notify staff when leaving;
-Encourage resident to talk to staff prior becoming too stress that he has to leave
facility;
-Target date 03/12/19.
Record review of nurse’s notes dated 11/25/18, at 9:16 P.M., showed resident was on leave
of absence from the facility and returned after he/she attended church and watched movies
with his friends.
Record review of resident’s care plan, dated 11/26/18, showed the following:
-Resident is an elopement risk/wanderer with a history of attempts to leave facility
unattended, not sign out, impaired safety awareness;
-The resident will not leave the facility unattended through the review date;
-Identify pattern of wandering;
-Target date 03/12/19.
Record review of the resident’s social service notes dated 11/27/18, at 5:38 P.M., showed
staff met with resident to ensure he/she remembered to sign out and let staff know if
he/she is leaving the building.
Record review of resident’s nurse’s note dated 12/01/18, at 11:02 P.M., showed the
resident left the facility at 6:15 P.M. to attend a play and returned at 10:30 P.M.
Record review of resident’s social services note dated 12/26/18, at 10:45 A.M., showed
staff asked the resident where he/she was on the evening of 12/24/18. The resident said
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265188

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

SPRING VALLEY HEALTH & REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

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 0656

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 15)
he/she left the facility to visit a friend and to attend late church. The resident advised
he/she told the nursing staff where he/she was going and signed out.
3. During an interview on 05/07/19, at 1:18 P.M., Social Services (SS) said care plan
goals should coincide. He/she reviews the care plans to make ensure they do not have
conflict information.
4. During an interview on 05/07/19, at 1:18 P.M., the MDS Coordinator said care plans that
are due for review are discussed that month at the weekly care plan meeting with the
interdisciplinary team (IDT). The IDT will review care plans to ensure there is no
conflicting information.
5. During an interview on 05/07/19, at 3:30 P.M., the Administrator said care plans should
not have conflicting information.

F 0676

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Ensure residents do not lose the ability to perform activities of daily living unless
there is a medical reason.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview, and record review, the facility failed to provide
adequate assistance with dining to one resident (Resident #236) who was at risk for
aspiration and required extensive assistance with eating. A sampled of 32 residents was
selected for review in a facility with a census of 142
1. Record review of Resident #236’s admission record (face sheet) showed the resident
admitted to the facility on [DATE] from the hospital.
Record review of the resident’s medication review report, dated (MONTH) 2019, showed a
physician order, dated 4/11/19, for regular diet, mechanical soft texture.
Record review of the resident’s care plan, dated 4/11/19, showed the following:
-Resident has an activities of daily living (ADL- dressing, grooming, bathing, eating, and
toileting) self-care performance deficit related to [MEDICAL CONDITION] and stroke
diagnoses;
-Resident requires extensive assistant by one staff to eat, aspiration risk;
-Resident has a communication problem related to [MEDICAL CONDITION];
-Staff to anticipate and meet needs;
-Resident is able to nod head yes or no;
-Requires tube feeding related to dysphagia.
Record review of the resident’s speech therapy evaluation and plan of treatment, dated
4/12/19, showed, recommendation of close supervision during oral intake.
Record review of the resident’s admission Minimum Data Set (MDS – a federally mandated
comprehensive assessment took completed by facility staff), dated 4/18/19, showed the
following:
-Severe cognitive impairment;
-Disorganized thinking, behavior present, fluctuates (comes and goes);
-Required extensive assistance of one staff with eating;
-Functional limitation in range of motion, upper extremity and lower extremity impairment
on one side;
-Wheelchair for mobility device;
-[DIAGNOSES REDACTED].
-Resident has feeding tube and consumes mechanically altered diet for nutritional needs.

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265188

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

SPRING VALLEY HEALTH & REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

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 0676

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 16)
Observation on 4/29/19 showed the following:
-At 1:05 P.M., the resident sat in his/her wheelchair at a dining room table;
-The resident’s immobile right arm rested on a half tray connected to the wheelchair;
-The resident’s plate held a small biscuit and plain iceberg lettuce. The resident also
had a small bowl of stew, a piece of cake in a Styrofoam bowl, an unopened packet of salad
dressing, and an unopened tub of butter on his/her table;
-The resident did not have any drinks on his/her table;
-The resident attempted to eat plain lettuce off a plate with his/her left fingers;
-The resident attempted to eat a few bites of the stew with a fork using his/her left
hand, but was unable to get any meat or vegetables to stay on the fork;
-At 1:10 P.M., a certified nursing assistant (CNA) walked over to the resident’s table and
handed the resident an open carton of milk with no glass or straw;
-The CNA said to the resident, If you need anything else, let me know, and walked away;
-The resident looked confused, but attempted to drink the milk from the carton out of the
side of the open spout, milk spilled down the resident’s chin;
-The resident attempted to get a bite of cake out of the Styrofoam bowl, but was unable
to. The resident dumped the cake out of the bowl onto the plate and ate the cake with
his/her fingers;
-The CNA did not offer to put salad dressing on the resident’s salad; did not offer to
cut, open, or butter the biscuit; did not offer the resident a cup of a straw for the
carton of milk; and did not offer the resident a spoon for the stew;
-At 1:15 P.M. a CNA asked from approximately 10 feet away if the resident is doing okay,
the resident nods his/her head up and down;
-At 1:20 P.M., the resident has consumed approximately approximately 25 % of his her lunch
and drank most of the carton of milk;
-A CNA walked up behind the resident and pulled the resident away from the table without
speaking to the resident;
-The CNA propelled the resident to the hallway near the nurse’s station and left the
resident.
Observation on 4/30/19, at 12:40 P.M., showed the following:
-The resident lay in bed asking if staff were getting him/her up out of bed for lunch.
Observation on 4/30/19, at 1:20 P.M., showed the following:
-The resident lay in bed with the head of the bed elevated approximately 30 degrees;
-Staff had positioned the resident’s over bed table across the resident’s bed;
-No staff were present to assist the resident or to monitor for swallowing problems;
-The plate held a slice of plain bread, an unopened tub of butter, buttered pasta with no
sauce, and ground meat with stewed chunks on the meat, the resident had a glass of
lemonade to drink;
-The resident attempted to eat the pasta with a fork, but the pasta slid around the
resident’s plate.
Observation and interview on 5/01/19, at 1:15 P.M., showed the following:
-The resident lay in bed with a lunch tray on the over bed table across the resident’s
bed;
-The resident ate stuffing covered with gravy and a dry roll, the resident pointed to the
meat and asked this surveyor what it was, when the surveyor replied pork roast, the
resident shoved the entire over table away from the bed and frowned;
-The resident indicated he/she did not like pork because of religious reasons;
-The resident indicated no staff had asked the resident about his/her food preferences;
-No staff were present to assist the resident, offer an alternative, or monitor the
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265188

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

SPRING VALLEY HEALTH & REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

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 0676

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 17)
resident for swallowing problems.
Observation on 5/02/19, at 12:15 P.M., showed the following:
-The resident lay in bed, alone in the room with the tray table across the bed with a
lunch plate which held chicken, peas, and carrots, and a slice of bread;
-The resident’s drinks were out of his/her reach.
-The resident’s call light was connected to the bed frame below the level of the mattress
on the right side, out of the resident’s sight and reach.
During an interview on 5/07/19, at 8:20 A.M., the Speech Therapist (ST) JJ, said the
resident needs supervision and cueing with meals and assistance with opening containers
and cutting up food.
During an interview on 5/07/19, at 11:05 P.M., the Director of Nursing (DON) said all
staff should ensure the resident’s call light is in the resident’s reach before leaving
the resident’s room.
During an interview on 5/07/19, at 3:15 P.M., the administrator and DON said the
following:
-A nurse should be present in the dining room during meals;
-Staff should assist residents with opening containers, pouring milk into glasses, and
with dining assistance if needed during meals.
MO 938 and MO 041

F 0684

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Provide appropriate treatment and care according to orders, resident’s preferences and
goals.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview, and record review, the facility failed to obtain orders
regarding when to change a Peripherally Inserted Central Catheter (PICC line-a type of
catheter that is inserted through a peripheral vein, often in the arm, into a larger vein
in the body, used when intravenous treatment is required over a long period) dressing and
failed to change the dressing per standards of practice for one sampled resident (Resident
#243) as ordered; failed to complete treatments per physician order [REDACTED].
1. Record review of the(NAME)Medicine Interdisciplinary Clinic Practice Manual, Infection
Control, Vascular Access Device Policy, Dated [DATE], a semi-permeable sterile transparent
dressing in the appropriate size shall be used and is changed every seven days or when it
becomes damp, loose, soiled or if the patient develops problems at the site that require
further inspection.
Record review showed the facility did not provide a policy showing regarding the specific
timing for PICC-line dressing changes.
Record review of Resident #243’s face sheet (a summary of important information about a
resident) showed the following:
-admitted on [DATE];
-[DIAGNOSES REDACTED].
Record review of the resident’s physician’s orders [REDACTED].
-Staff did not document an order to change a PICC line dressing;
-On [DATE], an order was received for [MEDICATION NAME] (broad-spectrum antibiotic), two
grams intravenously one time daily for 25 days.
Record review of the resident’s admission minimum data set (MDS – a federally mandated

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265188

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

SPRING VALLEY HEALTH & REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

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 0684

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 18)
comprehensive assessment tool completed by facility staff), dated [DATE], showed no PICC
line or IV medication.
Record review of the resident’s care plan, dated [DATE], showed a care plan entry for the
PICC line. Staff did not address how often to change the PICC line dressing on the care
plan.
Record review of the resident’s admission note dated [DATE], at 7:28 P.M., showed the
following:
-Resident was alert and oriented x 4;
-Resident had multiple bruises over abdomen at different healing stages;
-Port for [MEDICAL TREATMENT] (a process where wastes, salts, and fluid are filtered from
blood when kidneys are no longer healthy enough to do this work adequately): Right
tunneled intra-jugular (IJ) catheter (a thin tube that is placed under the skin in a vein,
most commonly in the neck) placed [DATE]. Left SVC Powerline Double Lumen (a PICC line
with two separate tubings leading into the same line) placed [DATE].
Record review of the resident’s (MONTH) 2019 and (MONTH) 2019 treatment administration
record (TAR) showed:
-No order to change the PICC line dressing in (MONTH) or (MONTH) 2019;
-No documentation of the PICC line dressing being changed in either (MONTH) or April.
Record review of the resident’s [MEDICAL TREATMENT] Communication Record, dated [DATE],
showed a note from a [MEDICAL TREATMENT] nurse to the facility which showed, Also
concerned about Patient’s PICC line dressing. Has not been changed since it was placed.
Who is responsible of changing that dressing?
Record review of the resident’s nurse’s note dated [DATE], at 2:17 P.M., showed staff
returned call to [MEDICAL TREATMENT] about PICC line. Notified nurse that staff are
removing here at facility. Resident has completed antibiotic therapy and is being
discharged on [DATE] to home health care.
During an interview on [DATE], at 11:37 A.M., the admissions nurse said the following:
-Every new admission with a PICC line gets a dressing change the day after admission and
every seven (7) days;
-Any time a resident with a PICC line was admitted , orders are added that say to change
dressing every seven days and flush line every shift. If the admission came during a shift
he/she wasn’t working the floor, nurses might not know to put the order in; however, they
should know to do the actual tasks.
During an interview on [DATE] at 2:05 P.M. Registered Nurse (RN) D said:
-Dressing changes to PICC line can be done by the RN only. If there is not an RN available
to change the dressing, one of the unit managers will do it;
-Dressings to PICC lines and central lines are to be changed every seven days;
– If a resident admits to the facility and no orders to change the dressing are sent from
the hospital, they are put in place upon admission.
During an interview on [DATE], at 3:15 P.M., the Director of Nursing (DON) said:
-PICC line dressing should be changed within the first 24 hours of admission then weekly
and as needed;
-RNs only change the PICC line dressing;
-She was unaware of the communication from [MEDICAL TREATMENT] regarding the resident.
2. Record review of the Resident #93’s face sheet (gives basic information) showed the
following:
-admitted to the facility [DATE];
-Admitting [DIAGNOSES REDACTED]., [MEDICAL CONDITIONS] ([MEDICAL CONDITION]).
Record review of the resident’s current care plan, reviewed on [DATE], showed the
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265188

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

SPRING VALLEY HEALTH & REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

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 0684

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 19)
following:
-On [DATE], actual impairment to skin integrity of the abdomen related to surgical wound,
small bowel resection hernia repair with infected mesh;
-On [DATE], goal of skin injury abdominal wound to be healed;
-On [DATE], interventions of monitor and document location, size and treatment of
[REDACTED].
Record review of the resident’s (MONTH) 2019 physician order [REDACTED].
-An order dated [DATE], for treatment to midline incision wound abdomen. Treatment ordered
included cleanse with normal saline (NS), apply wet/dry (moistened, not dripping) Kerlix
(gauze) rol in wound bed, cover with ABD (gauze) pad, secure with [MEDICATION NAME]
(breathable, flexible) tape; every day and evening shift;
-An order dated [DATE], for treatment to drain tube of right lower abdomen. Treatment
ordered flush with 5 to 10 cubic centiliters (cc) NS, every shift;
-An order dated [DATE], for treatment to small abdominal wound. Treatment ordered included
clean with normal saline (NS), apply moistened ,[DATE] inch packing gauze in wound, cover
with gauze, and secure with [MEDICATION NAME] (breathable, flexible) tape every day and
evening shift.
Record review of the resident’s (MONTH) 2019 treatment administration record (TAR) showed
the following:
-An order dated [DATE], clarified [DATE], for treatment to drain tube of right lower
abdomen. Treatment included measure output and flush with 5 to 10 cc NS every shift. Staff
did not document completion of the treatment on 4 of 22 opportunities;
-An order dated [DATE], for treatment to small abdominal wound. Treatment included clean
with NS, apply moistened ,[DATE] inch packing gauze in wound, cover with gauze, secure
with [MEDICATION NAME] tape every day and evening shift. Staff did not document completion
of the treatment on 4 of 22 opportunities;
-An order dated [DATE], for treatment to midline incision wound abdomen. Treatment
included apply wet/dry (moistened, not dripping) Kerlix rol in wound bed, cover with ABD
pad, secure with [MEDICATION NAME] tape; every day and evening shift. Staff did not
document completion of the treatment on 4 of 22 opportunities.
Record review of the resident’s (MONTH) 2019 TAR showed the following:
-An order dated [DATE], clarified [DATE], for treatment to the drain tube of the right
lower abdomen. Treatment included measure output and flush with 5 to 10 cc NS every shift.
Staff did not document completion of the treatment on 14 of 60 opportunities;
-An order dated [DATE], for treatment to small abdominal wound. Treatment included clean
with normal saline (NS), apply moistened ,[DATE] inch packing gauze in wound, cover with
gauze, secure with [MEDICATION NAME] tape, every day and evening shift. Staff documented
did not document completion of the treatment on 12 of 60 opportunities;
-An order dated [DATE], for treatment to midline incision wound abdomen. Treatment
included apply wet/dry (moistened, not dripping) Kerlix rol in wound bed, cover with ABD
pad, secure with [MEDICATION NAME] tape, every day and evening shift. Staff did not
document completion of the treatment on 12 of 60 opportunities;
During an interview on [DATE], at 10:40 A.M., the resident said staff did not always
change his/her wound dressing and empty the drain tube as directed by the physician’s
orders [REDACTED].
Record review of the resident’s current care plan, reviewed on [DATE], showed the
following:
-On [DATE], infection of the abdominal wall;
-On [DATE], goal for resident to be free from complications related to infection;
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265188

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

SPRING VALLEY HEALTH & REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

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 0684

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 20)
-On [DATE], interventions of administer antibiotic as per physician orders, maintain
universal precautions when providing resident care.
Record review of the resident’s (MONTH) 2019 TAR showed the following:
-An order dated [DATE], for treatment to drain tube of the right lower abdomen. Treatment
included measure output and flush with 5 to 10 cc NS every shift. Staff did not document
completion of the treatment on 3 of 18 opportunities.
During an interview on [DATE], at 1:45 P.M., RN K said the floor nurses should complete
all treatments per physician orders. The nurse should document the treatment on the TAR
and note any descriptions in a progress note.
During an interview on [DATE], beginning at 3:16 P.M., the Director of Nursing (DON) said
the nurses were responsible for completing all dressing changes and other treatments
according to the physician orders. The nurse should document the treatment on the TAR and
make notes in the progress notes.
3. Record review of Resident #134’s face sheet showed the following information:
-admitted to the facility [DATE];
-[DIAGNOSES REDACTED].
-discharged to the mortician [DATE] at 10:15 A.M.
Record review of an Outside the Hospital Do-Not Resuscitate (DNR) Order showed the
resident’s next of kin signed the form on [DATE]. The attending physician for the skilled
nursing facility signed the form on [DATE].
Record review of a County Medical Examiners Office document entitled Notification of Death
in a Nursing Facility showed the following information:
-Admission Diagnosis: [REDACTED].
-No fall, accident, or unusual event while at facility;
-Not on hospice services;
-date of death : [DATE];
-Time of death: 9:15 A.M.
Record review of the resident’s progress notes showed an admission note that included the
following:
-admitted after a fall at home resulting in [MEDICAL CONDITION];
-Alert and oriented only to self; nonverbal and unable to make needs known;
-Next of kin stated resident was walking and talking prior to fall;
-Assessment showed lungs clear, breathing even and unlabored, oxygen saturation at 94% on
room air, heart rate 93 with regular rate and rhythm, denies pain or shortness of breath;
-Discussed code status with family; elected to sign DNR form, sent to physician for
signature.
Record review of the resident’s progress notes showed staff did not document information
pertaining to the resident’s death.
During an interview on [DATE] at 2:25 P.M., the medical records personnel said no written
documentation pertaining to the resident’s death was found in the closed medical record,
with the exception of the coroner notice.
During an interview on [DATE], at 3:50 P.M., the Director of Nursing (DON) said he/she was
unable to locate any nurses’ notes pertaining to the resident’s death. He/she did not
recall any details regarding the event. He/She would expect the nurse to document a
narrative regarding a death.
During an interview on [DATE] at 1:45 P.M., RN K said two nurses must assess a resident
and determine death has occurred. A nurse should notify the physician and resident’s
family and document the event in progress notes.
During an interview on [DATE] at 10:55 A.M., LPN M said if a resident expires in the
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265188

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

SPRING VALLEY HEALTH & REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

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 0684

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 21)
facility, a staff member should check the resident’s code status to determine whether or
not to begin or continue coronary [MEDICAL CONDITION] resuscitation (CPR). Staff should
record a time line of events and document the information in the progress notes.
4. Record review of Resident #94’s admission MDS, dated [DATE], showed the following:
-Resident re-entered the facility from the hospital on [DATE];
-Cognitively intact;
-No behaviors;
-Required extensive assistance of one staff with bed mobility, transfers, dressing,
personal hygiene, and toileting;
-Always continent of bowel and bladder;
-[DIAGNOSES REDACTED].
Record review of the resident’s current care plan, revised on [DATE], showed the
following:
-Resident has potential for impairment to skin integrity related to [MEDICAL CONDITION]
and impaired mobility;
-Encourage good nutrition and hydration in order to promote healthier skin;
-Identify and document potential causative factors and eliminate/resolve where possible;
-Weekly treatment documentation to include measuring each area of skin breakdown, type of
tissue, exudate, and any other notable changes in observations;
-Monitor/document/report any signs and symptoms of skin problems: redness, [MEDICAL
CONDITION], blistering, itching, burning, bruises, cuts, other [MEDICAL CONDITION].
Record review of the resident’s physician order [REDACTED].
-An order dated [DATE], for [MEDICATION NAME] powder (an antifungal medicated powder)
100,000 units/gram, apply to rash topically every six hours as needed for rash.
Record review of the resident’s (MONTH) 2019 TAR showed the following:
-An order dated [DATE], for [MEDICATION NAME] Powder 100,000 units/gram, apply to rash
topically every 6 hours as needed for rash;
-No nurses initialed completion of the treatment in (MONTH) 2019.
Record review of the resident’s (MONTH) 2019 TAR showed the following:
-An order dated [DATE], for [MEDICATION NAME] Powder 100,000 units/gram, apply to rash
topically every 6 hours as needed for rash;
-No nurses initialed completion of the treatment in (MONTH) 2019.
During an interview and observation on [DATE], at 2:30 P.M., the resident said the
following:
-The resident has a yeast infection to his/her groin;
-The resident cannot get staff to put medicine on the area;
-Staff brought the resident a bottle of [MEDICATION NAME] powder;
-The resident cannot put the powder on and needs assistance with it;
-The resident said his/her groin had, Really gotten bad;
-The resident said the yeast infection areas on his/her groin and inner thighs drain fluid
and the fluid gets the resident’s pants wet;
-A small bottle of [MEDICATION NAME] powder sat on the resident’s over bed table.
During an interview on [DATE], at 12:45 P.M., the resident said the following:
-The resident ran out of [MEDICATION NAME] powder approximately two to three days prior;
-The resident said he/she informed the nurses of the need to order [MEDICATION NAME]
powder.
During an interview on [DATE], at 12:50 P.M., Licensed Practical Nurse (LPN) NN said the
resident does not have a skin treatment to his/her groin.
Record review of the resident’s (MONTH) 2019 TAR showed the following:
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265188

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

SPRING VALLEY HEALTH & REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

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 0684

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 22)
-An order dated [DATE] for [MEDICATION NAME] Powder 100,000 units/gram, apply to rash
topically every 6 hours as needed for rash;
-No nurses initialed completion of the treatment in (MONTH) 2019.
Observation and interviews on [DATE], at 11:05 A.M., showed the following:
-Certified Nurse Aide (CNA) P and CNA OO entered the resident’s room to assist the
resident with changing his/her pants;
-The resident had peeling skin and redness to his/her inner upper thighs bilaterally, and
to his/her anterior and posterior groin;
-The resident said the areas are painful;
-The resident said staff are not performing treatments to the areas;
-CNA P said the resident did have [MEDICATION NAME] powder in his/her room in the past for
staff to apply to the yeast infected areas.
During an interview on [DATE], at 11:05 P.M., the DON said the following:
-She was not aware of any skin issues with the resident’s groin.
-The wound nurse should be checking all of the residents’ skin on a weekly basis and
documenting the findings.
MO 938, MO 963, MO 428, MO 429, and MO 467

F 0686

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview, and record review, the facility failed to meet the ensure
dietary recommendations were addressed timely, failed to ensure medications were
administered as ordered, failed to complete wound care following infections control
guidelines, and failed to ensure a wound was seen by a physican after a significant
declines for one resident (Resident #95) with two pressure ulcers. Staff failed to follow
acceptable methods of infection control when they did not wash their hands and change
gloves during wound treatment and staff failed to care plan the wound for one resident
(Resident #92). A sample of 35 residents were selected for review. The facility census was
142.
Record review of the facility’s skin management guidelines, revised (MONTH) (YEAR), showed
the following:
-Purpose to identify at risk residents for potential breakdown or ulcerations;
-Risk factors include impaired mobility, resident right of choice in some aspect of care
and treatment, under nutrition, malnutrition, and hydration deficits;
-Upon admission, all residents are assessed for skin integrity by completing an assessment
and documenting in the electronic health record (EHR). Following admission the Braden
scale should be completed quarterly and with a change in condition, for the risk of
development of pressure ulcers. Appropriate preventative measures will be implemented on
all residents identified as at risk and the intervention documented on the care plan;
-Residents admitted with skin impairments will have appropriate interventions implemented
to help to promote healing, a physician’s orders [REDACTED].
-Residents who are at risk or with wounds and/or pressure ulcers and those at risk for
skin compromise are identified, assessed and provided appropriate treatment to encourage
healing and/or integrity. Ongoing monitoring and evaluation are provided to ensure optimal
resident outcomes;

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265188

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

SPRING VALLEY HEALTH & REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

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

(continued… from page 23)
-Staging classification: the following staging classification is consistent with the
national pressure ulcer advisory panel (NPUAP). A pressure ulcer is a localized injury to
the skin and/or underlying tissue, usually over a bony prominence, as a result of pressure
or pressure in combination with shear and/or friction;
-Stage 1 pressure ulcer: Non-blanchable (a reddened area that does not temporarily turn
white or pale when pressure is applied; usually a result of impaired circulation)
[DIAGNOSES REDACTED] (redness) of intact skin;
-Stage 2 pressure ulcer: Partial-thickness skin loss with exposed dermis;
-Stage 3 pressure ulcer: Full thickness skin loss, in which adipose (fat) is visible in
the ulcer and granulation tissue (formation of new tissue, usually pink to red in color)
and epibole (rolled wound edges) are often present. Slough (non-viable yellow, tan, gray,
green or brown tissue; usually moist, can be soft, stringy and mucinous in texture) and/or
eschar (dead or devitalized tissue that is hard or soft in texture) may be visible. The
depth of tissue damage varies by anatomical location. Undermining and tunneling may occur.
Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or
eschar obscures the extent of tissue loss this is an unstageable pressure ulcer;
-Stage 4 pressure ulcer: Full thickness skin and tissue loss with exposed or directly
palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or
eschar may be visible. Epibole (rolled edges), undermining and/or tunneling often occur.
Depth varies by anatomical location. If slough or eschar obscures the extent of tissue
loss this is an unstageable pressure ulcer;
-Unstageable pressure ulcer: Obscured full-thickness skin and tissue loss in which the
extent of tissue damage within the ulcer cannot be confirmed because it is obscured by
slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure ulcer will
be revealed.
1. Record review of Resident #95’s admission record showed the following:
-admitted to the facility on [DATE] from the hospital;
-[DIAGNOSES REDACTED].), reduced mobility, and adult failure to thrive.
Record review of the resident’s physician order [REDACTED].
-Order for intravenous piggyback (IVPB) medication infusion of meropenem ([MEDICATION
NAME]) (an antibiotic) staff to administer 1000 milligrams (mg) every 8 hours for wound
infection for 27 days;
-Order for IVPB medication [MEDICATION NAME] (antiinfective) 1750 mg one time a day for
wound infection for 27 days;
-Negative pressure wound therapy 150 millimeters (mm)/mercury (hg) every day shift Monday
and Thursday for wound care;
-Daily-Vite (multi-vitamin) tablet give one tablet by mouth one time a day for supplement;
-Zinc sulfate tablet 110 mg give one tablet one time daily for supplement;
-Regular diet with double portions and high protein diet with supplements.
Record review of the resident’s pressure injury risk assessment, dated 2/28/19, showed the
resident is a moderate risk.
Record review of the resident’s nursing admission screening/history, signed 3/01/19,
showed the following:
-admitted from the hospital;
-Reason for admission was wound care and intravenous (IV) antibiotic therapy;
-Sacral ulcer;
-Stage 4 pressure ulcer to sacrum measured 13 centimeters (cm) in length by 15 cm in width
by 6 cm in depth;
-Right ischial (hip bone) pressure ulcer (no stage listed) 7.0 cm in length by 7.0 cm in
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265188

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

SPRING VALLEY HEALTH & REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

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

(continued… from page 24)
width by 6.0 cm in depth with an irregular shape.
Record review of the resident’s weekly wound observation, dated 3/01/19, completed by the
facility wound nurse, showed the following:
-Stage 4 pressure ulcer sacrum to left buttock to ischial area;
-Slough tissue present (yellow, tan, white, stringy);
-Unable to determine the extent of necrosis and/or slough in the wound bed;
-Scant amount of serosanguineous drainage;
-No odor to wound;
-Wound measurements: 13.0 cm in length by 15.0 cm in width by 6.0 cm in depth;
-Peri-wound pink blanching normal in color;
-Wound edges and shape are irregular;
-Current treatment plan: [REDACTED]
-Wound present on admission.
Record review of the resident’s physician order [REDACTED].
-An order dated 3/4/19, for negative pressure wound therapy 150 mm/hg every day shift
every Monday and Thursday for wound care.
Record review of the resident’s admission minimum data set (MDS – a federally mandated
assessment tool completed by facility staff), dated 3/07/19, showed the following:
-Severe cognitive impairment;
-Did not reject care;
-Required extensive assistance of 2 or more staff with bed mobility, dressing, toileting,
and personal hygiene;
-Impaired range of motion to both lower extremities;
-Wheelchair for mobility;
-Has one stage 3 pressure ulcers, 2 stage 4 pressure ulcers and 2 unstageable pressure
ulcers;
-Pressure reducing device to chair and bed;
-Staff apply dressings and ointments/medications to resident’s skin.
Record review of the resident’s nutritional assessment, dated 3/07/19, completed by the
dietitian, showed the following:
-Plan/recommendations to change daily vite to multivitamin with minerals, evaluate the
discontinuation of zinc sulfate after 14 days use, start Prosource 30 milliliters (ml) two
times per day, and draw [MEDICATION NAME] lab.
Record review of the skin observation tool, dated 3/08/19, completed by the facility wound
nurse, showed the following:
-Resident frequently complains of discomfort with wounds, he/she has additional wound
report.
Record review of the resident’s weekly wound observation, dated 3/08/19, completed by the
facility wound nurse, showed the following:
-Stage 4 sacral pressure ulcer;
-Overall impression, wound is improving;
-[MEDICATION NAME] tissue present (pink);
-Granulation tissue present (beefy red);
-Slough tissue present (yellow, tan, white, stringy);
-5% necrosis and/or slough in the wound bed;
-Scant amount of serosanguineous drainage;
-No odor to wound;
-Wound measurements: 15.0 cm in length by 15.0 cm in width by 5.0 cm in depth;
-Peri-wound pink blanching normal in color;
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265188

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

SPRING VALLEY HEALTH & REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

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

(continued… from page 25)
-Wound edges and shape=irregular at one edge and well defined on the other edge;
-Current treatment plan: [REDACTED]
-Wound present on admission;
-Slowly improving cleaner than previous.
Record review of the resident’s weekly wound observation, dated 3/08/19, completed by the
facility wound nurse, showed the following:
-Stage 3 right gluteal/posterior thigh pressure ulcer;
-Overall impression, wound is improving;
-Granulation tissue present (beefy red);
-Scant amount of serosanguineous drainage;
-No odor to wound;
-Wound measurements: 5.5 cm in length by 4.4 cm in width by 2.0 cm in depth;
-Peri-wound pink blanching, no increased temperature;
-Wound edges and shape=rolled, well defined;
-Current treatment plan: [REDACTED]
-Resident non-compliant with leaving dressing intact, will begin peeling at dressing
immediately upon completion;
-Cleaner than previously observed.
Record review of the resident’s care plan, dated 3/13/19, showed the following
-Has nutritional problem or potential nutritional problem related to alteration in skin
integrity related to pressure ulcers;
-Administer medications as ordered;
-Obtain and monitor lab and diagnostic work as ordered. Report results to the resident’s
physician and follow up as indicated;
-Provide and serve diet as ordered.
Record review of the resident’s weekly wound observation, dated 3/15/19, completed by the
facility wound nurse, showed the following:
-Stage 3 coccyx (tailbone) pressure ulcer;
-Overall impression, unchanged;
-Visible tissue moist;
-5% necrosis and/or slough in the wound bed;
-Scant amount of serous drainage;
-No odor to wound;
-Wound measurements: 15.0 cm in length by 14.6 cm in width by 5.0 cm in depth;
-Peri-wound pink blanches;
-Wound edges and shape=rolled;
-Current treatment plan: [REDACTED]
-Wound progress= little change.
Record review of the skin observation tool, signed 3/17/19, completed by the facility
wound nurse, showed the following:
-Resident frequently complains of discomfort with wounds, he/she has additional wound
report.
Record review of the resident’s weekly wound observation, dated 3/17/19, completed by the
facility wound nurse, showed the following:
-Stage 3 right posterior thigh pressure ulcer;
-Overall impression, wound is improving;
-Visible tissue moist
-Scant amount of serous drainage;
-No odor to wound;
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265188

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

SPRING VALLEY HEALTH & REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

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

(continued… from page 26)
-Wound measurements: 4.3 cm in length by 5.6 cm in width by 1.8 cm in depth;
-Peri-wound pink blanching, no induration;
-Wound edges and shape=rolled;
-Current treatment plan: [REDACTED]
-Cleaner than previous.
Record review of the resident’s (MONTH) 2019 physician order [REDACTED].
-A order dated 3/18/19, for Prosource (nutritional supplement) give 30 ml by mouth three
times per day.
(This order came 11 days after dietitian recommendation to start Prosource.)
Record review of the resident’s care plan, revised on 3/20/19, showed the following:
-Resident has (multiple) pressure ulcers;
-Assess/record/monitor wound healing sacrum, both hips, left buttock, right heel;
-Measure length, width, and depth where possible;
-Assess and document status of wound perimeter, wound bed and healing progress. Report
improvements and declines to the physician;
-Follow facility policies/protocols for the prevention/treatment of
[REDACTED].>-Monitor/document/report as needed any changes in skin status: appearance,
color, wound healing signs/symptoms of infection, wound size (length by width by depth),
and stage.
Record review of the skin observation tool, dated 3/28/19, completed by the facility wound
nurse, showed the following:
-Resident states he/she always hurts.
Record review of the resident’s 30-day MDS, dated [DATE], showed the following:
-Resident admitted to the facility on [DATE];
-Moderately impaired cognitive ability;
-Exhibits inattention and disorganized thinking, behaviors present, fluctuate (comes and
goes, changes in severity);
-Delusions;
-Verbal behavioral symptoms directed toward others and not directed toward others,
occurred 4-6 days in a week, but less than daily;
-Rejection of care 4-6 days in a week;
-Required extensive assistance of one staff with bed mobility, dressing, toileting, and
personal hygiene;
-Transfers, activity only occurred once or twice, resident required assistance of two or
more staff;
-Functional limitation in range of motion or both lower extremities;
-Wheelchair for mobility device;
-[DIAGNOSES REDACTED].
-Resident has one stage 3 pressure ulcer, two stage 4 pressure ulcers, and two unstageable
pressure ulcers;
-Resident has pressure reducing device for chair and bed;
-Resident takes as needed pain medication for frequent pain, rates pain a 6 on a scale of
0-10.
Record review of the resident’s physician order [REDACTED].
-An order dated 3/28/19, for treatment to coccyx/sacrum and right gluteal fold. Treatment
included [DEVICE] negative pressure therapy 150 mm/hg every day shift every Monday and
Thursday on the day shift for wounds related to pressure ulcer of sacral region, stage 4.
Record review of the resident’s care plan, revised on 3/31/19, showed the following:
-Resident is resistive to [DEVICE] at times as well as removing dressings;
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265188

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

SPRING VALLEY HEALTH & REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

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

(continued… from page 27)
-Allow the resident to make decisions about treatment regime, to provide a sense of
control;
-Give clear explanation of all care activities prior to and as they occur during each
contact.
Record review of the resident’s (MONTH) 2019 Registered Nurse (RN)/Licensed Practical
Nurse (LPN) Medication Administration Record [REDACTED]
-Nurses failed to sign administration of the resident’s Meropenem 1000 mg per IV ordered
every 8 hours for wound infection for 27 days (beginning on 2/28/19);
-Nurses failed to sign administration of the Meropenem 6:00 A.M., dose on 3/14/19,
3/19/19, and 3/27/19;
-Nurses failed to sign administration of the Meropenem 2:00 P.M. dose on 3/05/19, 3/06/19,
3/10/19, 3/15/19, 3/16/19, and 3/18/19-3/23/19;
-Nurses failed to sign administration of the Meropenem 10:00 P.M. dose on 3/11/19,
3/14/19, and 3/25/19;
-Staff did not document the reason for the missed doses.
Record review of the skin observation tool, dated 4/05/19, completed by the facility wound
nurse, showed the following:
-Coccyx wound was 9.4 cm in length by 12 cm in width by 3.4 cm in depth, red beefy
granulation wound base, tunnel at 9 o’clock 2.2 cm depth;
-Right ischial wound was 4.2 cm in length by 1.3 cm in width by 0.1 cm in depth, red beefy
wound base.
Record review of the resident’s laboratory results, dated 4/08/19, showed the following:
-Resident’s white blood cell count result of 7.9 K/UL (reference range 4.0-10.00) result
is in normal range.
Record review of the resident’s weekly wound observation, signed 4/15/19, completed by the
facility wound nurse, showed the following:
-Stage 4 coccyx pressure ulcer;
-Overall impression, improving;
-Granulation tissue present (beefy red) and moist;
-No necrosis and/or slough in the wound bed;
-Moderate amount of serosanguineous (containing or consisting of both blood and serous
fluid) drainage;
-No odor to wound;
-Wound measurements: 9.2 cm in length by 11.5 cm in width by 3.4 cm in depth;
-Peri-wound pink blanching normal in color;
-Wound edges and shape=well defined;
-Current treatment plan: [REDACTED]
-Wound progress= healing.
Record review of the resident’s weekly wound observation, signed 4/15/19, completed by the
facility wound nurse, showed the following:
-Stage 4 right ischial pressure ulcer;
-Overall impression, wound is improving;
-Visible tissue granulation tissue present (beefy red) and moist;
-Moderate amount of serosanguineous drainage;
-No odor to wound;
-Wound measurements: 4.0 cm in length by 3.2 cm in width by 3.6 cm in depth;
-Peri-wound pink blanching, normal in color;
-Wound edges and shape= well defined;
-Current treatment plan: [REDACTED]
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265188

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

SPRING VALLEY HEALTH & REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

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

(continued… from page 28)
-Wound progress= healing.
Record review of the resident’s physician progress notes [REDACTED].
-Resident was seen and examined today. Resident continues to tolerate wound vac. Strong
odor noticeable. No concerns or new events reported by the nursing staff;
-Skin color, texture, turgor normal. No rashes or [MEDICAL CONDITION], sacral wound not
assessed;
-Assessment and plan: infected sacral pressure ulcer and right ischial pressure ulcer and
probable osteo[DIAGNOSES REDACTED] sacrum;
-status [REDACTED].>-Completed [MEDICATION NAME] (and IV [MEDICATION NAME];
-Continue [DEVICE];
-Follow up with wound clinic and infectiousdisease.
Record review of the resident’s progress note dated 4/18/19, at 1:53 P.M., showed a nurse
documented the following:
-Resident returned from the infectious disease physician office on 4/17/19 with the
following note from the physician indicating the wounds are doing well and to call for an
appointment if the wounds are doing poorly. The resident’s FNP notified of the report, no
new orders at this time.
Record review of the resident’s family nurse practitioner (FNP) progress note, dated
4/18/19, showed the following:
-Resident was seen and examined today. Resident is up in a wheelchair. Resident denies any
specific complaints. Pain is controlled. Resident continues to tolerate the [DEVICE].
Encouraged offloading to his/her sacral wound as the resident has been up in a wheelchair
10 or more hours per day for the past two weeks. No concerns or new events reported by the
nursing staff;
-Skin color, texture, turgor normal. No rashes or [MEDICAL CONDITION], sacral wound with
[DEVICE] in place and declining per nursing report, no signs of infection;
-Assessment and plan: Infected sacral pressure ulcer and right ischial ulcer and probable
osteo[DIAGNOSES REDACTED] sacrum
-status [REDACTED].>-Completed [MEDICATION NAME] and IV [MEDICATION NAME];
-Continue wound VAC;
-Follow up with wound clinic and ID.
Record review of the resident’s weekly wound observation, signed 4/19/19, completed by the
facility wound nurse, showed the following:
-FNP notified of wound status deterioration on 4/19/19 (Friday);
-Stage 4 coccyx pressure ulcer;
-Overall impression, worsening;
-Granulation tissue present (beefy red) and moist;
-Necrotic tissue present (brown, black, leather, scab-like);
-Resident noted with three necrotic areas to wound base related to extended time in the
wheelchair, refusing to lie down;
-5% necrosis and/or slough in the wound bed;
-Moderate amount of serosanguineous drainage;
-Odor present to wound;
-Wound measurements: 11.0 cm in length by 11.0 cm in width by 3.5 cm in depth;
-No tunneling or undermining;
-Peri-wound pink blanches normal in color and temperature;
-Wound edges and shape=well defined;
-Current treatment plan: [REDACTED]
-Wound progress= Wound has deteriorated with 3 necrotic areas at 8 o’clock 1.5 cm by 1.4
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265188

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

SPRING VALLEY HEALTH & REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

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

(continued… from page 29)
cm, at 6 o’clock 2.0 cm by 3.5 cm by 2.0 cm, center of wound base 4.0 cm by 0.4 cm black
to gray line;
-Continue to educate resident to the need of relieving pressure to area at least every two
hours. Resident will respond, I know, but I’m tired and don’t want to spend my life in
bed.
Record review of the resident’s weekly wound observation, signed 4/19/19, completed by the
facility wound nurse, showed the following:
-FNP notified of wound status deterioration on 4/19/19;
-Stage 4 right ischial pressure ulcer;
-Overall impression, wound is improving;
-Visible tissue [MEDICATION NAME] tissue present (pink);
-Small amount of serosanguineous drainage;
-Wound measurements: 4.4 cm in length by 2.5 cm in width by 5.6 cm in depth;
-Peri-wound pink blanching, normal in color and temperature;
-Wound edges and shape= well defined;
-Current treatment plan: [REDACTED]
-Wound progress= showing reserved progress at this time.
Record review of the resident’s nurse progress notes dated 4/22/19, at 3:54 P.M., showed
the wound nurse documented the following:
-[DEVICE] dressing change this date;
-Resident noted to have dark necrotic increase to surface of coccyx wound;
-Resident educated that the wound has deteriorated related to his increased amount of time
in wheelchair and decline request from staff to lay down and relieve pressure to coccyx
wound;
-Wound has foul odor and increased drainage;
-Notified the resident’s physician of the wound and requested lab and culture of wound
with next [DEVICE] change.
Record review of the resident’s physician progress notes [REDACTED].
-Skin color, texture, turgor normal, no rashes or [MEDICAL CONDITION], sacral wound not
assessed but reportedly stable;
-Assessment and plan: Infected sacral pressure ulcer and right ischial ulcer and probable
osteo[DIAGNOSES REDACTED] sacrum
-status [REDACTED].>-Completed [MEDICATION NAME] and IV [MEDICATION NAME]
-Continue wound VAC;
-Follow up with wound clinic and ID.
Record review of resident’s care plan, dated 4/23/19, showed the following
-Resident is non-compliant with cares, will refuse dressing changes, will loosen and try
to pull [DEVICE] off, resident will stay up in wheelchair for hours and refuses to lay
down to take pressure off his coccyx/sacral area;
-Educate the resident on the consequences of his noncompliance with relieving pressure,
allowing the dressing changes to be done as ordered;
-Encourage the resident to lay down frequently during the day.
Record review of the resident’s nurse progress notes dated 4/23/19, at 8:22 A.M., showed
the following:
-Physician order [REDACTED].
Record review of the resident’s nurse progress notes, dated 4/23/19, showed the following:
-At 1:03 P.M., a nurse documented he/she called the wound clinic to set up an appointment
for the resident and left a message for a return call;
-At 2:28 P.M., a nurse documented the wound clinic returned call and would send paperwork
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265188

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

SPRING VALLEY HEALTH & REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

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

(continued… from page 30)
for the facility to fill out and return to set up an appointment for the resident.
Record review of the resident’s laboratory results, dated 4/23/19, showed the following:
-The resident’s white blood cell count result of 13.3 K/UL (cubic millilieter) (reference
range 4.8-10.8) result is above normal range.
Record review of the resident’s nurse progress notes dated 4/24/19, at 8:36 A.M., showed
the following:
-A nurse documented paperwork completed and faxed back to the wound clinic, waiting for
the wound clinic to review and give appointment for wound clinic.
During an interview on 4/24/19, at 10:15 A.M., the RN Q, the facility wound nurse, said
the following:
-The wound nurse completes one hall of skin assessments/wound assessments/treatments per
day;
-The wound nurse attempts to get to each hall in the facility (except the dementia unit)
one day per week;
-The resident had multiple pressure ulcers on admission;
-The resident currently has a stage 4 pressure ulcer to his/her coccyx and a stage 4
pressure ulcer to his/her right ischium, both with current treatments for [DEVICE];
-The facility is attempting to set up an appointment for the wound clinic because the
coccyx wound is deteriorating.
During observation and interview on 4/24/19, at 11:50 A.M., the resident lay in bed and a
strong foul odor permeated the resident’s room. The resident said he/she spoke to the
administrator because some of the nurses were refusing to change his/her pressure ulcer
dressings. The resident said the issue is better.
Observation and interview on 04/25/19, at 11:15 A.M., showed the following:
-A foul odor present in the hallway outside of the resident’s room. Upon entering the room
the smell became very strong;
-RN Q entered the resident’s room to perform wound care to the resident’s pressure ulcers;
-The resident’s existing [DEVICE] dressing appeared displaced and rolled off halfway
(dated 422), a persistent odor of rotten eggs permeated the room;
-The RN removed the resident’s [DEVICE] dressing exposing a coccyx pressure ulcer
presenting as a deep crater, the approximate diameter of a cantaloupe and a right ischial
pressure ulcer presenting as a golf ball sized opening to a tunneling wound;
-The RN measured the resident’s coccyx pressure ulcer as 12.4 centimeters (cm) in length
by 14.0 cm in width by 3.0 cm in depth, with undermining from 9 to 10 o’clock with an
undermining lateral distance of 4.2 cm. The wound nurse described the wound base as 30%
necrotic tissue and 50% yellow slough. The peri-wound showed an area of redness spreading
out from the entire circumference of the wound measured approximately 3.0 cm wide;
-The RN said he/she was trying to get information to the wound clinic for a referral;
-The RN said the resident’s coccyx wound showed major deterioration within the past 5
days;
-The RN said the resident had a misunderstanding about the appropriate amount of time to
be up in a wheelchair;
-The RN measured the resident’s right ischial pressure ulcer as 3.5 cm in length by 5 cm
in width by 5.2 cm in depth with pink tissue to the wound;
-The RN said the resident removes his/her pressure ulcer dressings at times and at times
the dressings come loose during transfers/re-positioning;
-During the dressing change, the wound nurse cut black [DEVICE] foam to fit into the
coccyx pressure ulcer and placed the foam into the wound with gloved hands. The nurse’s
gloved fingers touched the pressure ulcer wound bed. The wound nurse then covered the foam
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265188

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

SPRING VALLEY HEALTH & REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

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

(continued… from page 31)
with clear adhesive. Without washing or sanitizing his/her hands, the wound nurse picked
up another piece of black foam wearing the same gloves and cut and placed the foam into
the ischial pressure ulcer. The nurses’ gloved fingers touched the pressure ulcer wound
bed. The nurse then covered the foam with wounds then covered second wound with clear
adhesive. The nurse then removed his/her gloves and cleaned his/her hands with alcohol
gel;
-The RN nurse said the resident’s physician looked at pictures of the resident’s pressure
ulcers on 4/23/19. The wound nurse said he/she took the photos on Thursday 4/18/19 and
Monday 4/22/19. The RN said the physician looked at the photos and ordered a wound consult
and a culture and sensitivity of the wound drainage;
-The RN said he/she consistently measured the pressure ulcers weekly, except for a period
of time in March, 2019 when the facility had staffing issues and the wound nurse was
pulled to work the floor as a charge nurse for three weeks;
-The RN said he/she noted an odor to the resident’s coccyx pressure ulcer on Thursday
4/18/19 and a deterioration in the appearance of the resident’s coccyx pressure ulcer on
Monday, 4/22/19. The pressure ulcer had an increased odor and an increase in the amount of
necrotic tissue.
During an interview on 4/26/19, at 9:50 A.M., Certified Nursing Assistant (CNA) P said the
following:
-The CNA said he/she could smell the odor of the resident’s pressure ulcer in the
resident’s room and outside of the resident’s room into the hall for approximately the
last one and one-half weeks;
-The CNA said the odor has continued to get worse.
During an interview on 4/26/19, at 10:15 A.M., the RN Q said the following:
-He/she just heard from the resident that the [DEVICE] needed changed and this is the
first the nurse knew about it;
-The wound nurse said he/she spoke to the resident’s physician on Monday 4/22/19 to notify
him/her of the condition of the resident’s pressure ulcer and the physician ordered wound
cultures and the lab picked up the wound cultures this AM on 4/26/19;
-The lab drew blood work for ordered lab tests on Tuesday 4/23/19, but the nurse was
unsure if the physician or nurse practitioner were aware of the results;
-The wound clinic called with an appointment scheduled for the resident, but the wound
clinic first available appointment is not until 5/10/19 (in two weeks from now).
During an observation on 4/26/19, at 10:20 A.M., the wound nurse informed the Director of
Nursing (DON) of the date of the resident’s wound clinic appointment and the DON asked if
the resident’s physician could get the resident into the wound clinic sooner and the wound
nurse said, no the physician could not get the resident in sooner.
During an interview on 4/26/19, at 10:25 A.M., the DON said the following:
-The DON said he/she makes rounds with the wound nurse every now and then;
-The DON said he/she saw part of the resident’s pressure ulcer on Monday night, 4/22/19;
-The DON said the resident’s dressing was coming off and the coccyx wound had an odor and
gray eschar covered approximately 80 % of the wound bed;
-The DON said he/she worked as a charge nurse on the evening shift, but he/she did not
change the dressing, but passed it on to the night shift that the resident’s dressing
needed changed;
-The DON said, other than that night, he/she had never seen the resident’s pressure
ulcers;
-The DON said he/she had never spoken the resident’s physician or nurse practitioner about
the resident’s pressure ulcers.
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265188

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

SPRING VALLEY HEALTH & REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

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

(continued… from page 32)
During an interview on 4/26/19, at 10:55 A.M., RN K said the following:
-He/she had never personally seen the resident’s pressure ulcers, but has viewed pictures
of the pressure ulcers;
-The RN said the resident received IV antibiotics from the time of admission, but when the
IV antibiotics were finished the resident started getting out of bed more;
-The RN said he/she believes the combination of being off the antibiotics and being out of
bed more (increased pressure to the ulcers) has led to a decline of the pressure ulcers;
-The RN said the resident’s coccyx pressure ulcer has necrotic tissue and an odor that it
probably did not have one week ago;
-The RN said the resident’s physician asked if he could see the resident’s pressure ulcer
and the wound nurse took a picture of her cell phone and showed the photo to the
physician, approximately three to four days ago, the RN said that was the same day that
the physician gave orders for a wound culture;
The RN said the resident’s coccyx pressure ulcer has had an odor for approximately 2
weeks, but in the past week the odor has gotten really bad;
-The RN said he/she believes the resident’s family nurse practitioner has looked at
his/her pressure ulcers.
During an interview on 4/26/19, at 1:22 P.M., the resident’s FNP said the following:
-The FNP has

F 0690

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Provide appropriate care for residents who are continent or incontinent of
bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract
infections.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview, and record review, the facility failed to ensure staff
performed catheter (a sterile tube inserted into the bladder to drain urine) care in a
manner to prevent potential urinary tract infections for one resident (Resident #92) of 32
sampled residents. The facility census was 142.
Record review of a facility’s policy and procedure entitled Catheter Care, dated (MONTH)
(YEAR), showed the following information:
-Wash hands and apply clean gloves;
-Cleanse the urethral meatus (the point where urine leaves the body) using soap and water
and a clean washcloth down the length of the catheter;
-Remove gloves and wash hands.
1. Record review of Resident #92’s face sheet (basic patient information) showed the
following information:
-admitted to the facility 3/13/19;
-[DIAGNOSES REDACTED].
Record review of the resident’s care plan, dated 3/15/19, showed the following
information:
-Has a [MEDICAL CONDITION] related to history of [MEDICAL CONDITION];
-Has an indwelling catheter related to [MEDICAL CONDITION].
Record review of the resident’s (MONTH) 2019 physician order [REDACTED].
-Maintain Foley catheter with size 16 French/10 cubic centiliter (cc) balloon for [MEDICAL
CONDITION]; change as needed for obstruction;
-An order dated 3/13/19, for indwelling catheter care every shift;

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265188

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

SPRING VALLEY HEALTH & REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

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

(continued… from page 33)
-An order dated 4/18/19, to change Foley catheter monthly for infection for prevention.
Observation on 5/6/19, at 3:17 P.M., showed Certified Medication Tech (CMT) N and LPN O
washed their hands and donned gloves prior to providing personal care to the resident,
stating the resident’s catheter was possibly leaking. CMT N and LPN O assisted the
resident to turn to his/her right side. CMT N rolled a saturated sheet and bed pad inside
toward the resident, tucking them under him/her. Without changing gloves or performing
hand hygiene, CMT N placed a clean sheet and bed pad on the bed, tucking them under the
resident as far as possible. CMT N and LPN O assisted the resident to turn over to his/her
left side. LPN O removed the wet sheet and bed pad. Without changing gloves or performing
hand hygiene, LPN O unrolled and positioned the clean sheet and bed pad and assisted the
resident to turn onto his/her back. Still wearing the same contaminated gloves, LPN O
secured the catheter tubing with his/her left hand and used his/her right hand to clean
the catheter tubing.
During an interview on 5/7/19, at 11:05 A.M., Certified Nurse Aide (CNA) P said staff
should wash their hands and don gloves prior to performing catheter care. Staff should
remove their gloves and wash their hands prior to proceeding to any other body part or
other task.
During an interview on 5/7/19, at 3:16 P.M., the Director of Nursing (DON) said staff
should wash their hands upon entering a resident’s room and prior to performing any care.
After completing the catheter care, staff should remove their gloves and wash or sanitize
their hands before touching other things or proceeding to another task.

F 0692

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Provide enough food/fluids to maintain a resident’s health.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview, and record review, the facility failed to implement,
monitor, and modify interventions, including Registered Dietitian recommendations, to
maintain acceptable parameters of nutritional status for three residents (Residents #81,
#117, and #242) out of a sample of 32 residents. The facility census was 142.
1. Record review of Resident #81’s face sheet (a one page summary of important information
about a resident) showed the following:
-Admission on 3/10/17;
-[DIAGNOSES REDACTED].
Record review of the resident’s vital signs showed the following:
-On 10/3/18, the resident weighted 127.1 pounds;
-On 10/3/18, the resident weighed 124.0 pounds.
Record review of the resident’s current physician order [REDACTED].
-An active order for a mechanical soft (foods that are physically soft) texture, with a
regular consistency liquid diet;
-an order for [REDACTED].
Record review of the resident’s progress notes dated 2/26/19, at 7:37 P.M., showed the
registered dietitian (RD) noted resident at 121.6 pounds with loss from 131.1 pounds since
September. The resident is within recommended weight range, however, further loss is
undesired. RD recommended Ensure Plus to 90 milliliter (ml) Med Pass Supplement three
times daily and monitor for stable weight pattern.
Record review of the resident’s Order Summary Report showed no new orders were entered

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265188

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

SPRING VALLEY HEALTH & REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

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 – Some

(continued… from page 34)
based on the RD’s recommendations.
Record review of the resident’s annual Minimum Data Set (MDS – a federally mandated
comprehensive assessment tool completed by facility staff), dated 3/19/19, showed the
following:
-Severe cognitive impairment;
-Needs supervision, oversight, encouragement or cueing for eating, and requires one-person
physical assist for eating.
Record review of the resident’s care plan, last revised on 3/28/19, showed the following:
-History of involuntary weight loss related to inadequate oral intake, as evidenced by
greater than 5% weight loss in one month;
-Staff is to encourage and assist as needed to consume foods and or supplements and fluids
offered, honor food preferences, provide diet as ordered, provide supplements as ordered,
review weights, and notify physician and responsible party of significant weight changes.
Record review of the resident’s vital signs showed the following:
-On 4/11/19, the resident weighed 111.2 pounds.
Record review of the resident’s progress note dated 4/19/19, at 9:08 A.M., showed a note
by the RD that resident is at 111.2 pounds with 8.9 pound loss in one month, 12.4 pound
loss in 3 months, and 15.9 pound loss in 6 months. Further loss is undesired. Diet is
mechanical soft with Ensure Plus twice daily. The RD recommended to change Ensure Plus to
90 ml Med Pass Supplement three times daily and add a multi vitamin with minerals
secondary to weight loss.
Record review of the resident’s Order Summary Report showed no new orders were entered
based on the RD’s recommendations.
2. Record review of Resident #117’s face sheet showed the following:
-Admission on 8/24/16;
-[DIAGNOSES REDACTED].
Record review of the resident’s vital sign charting showed the following:
-On 10/3/18, the resident weighed 203.5 pound.
Record review of the resident’s (MONTH) 2019 POS for (MONTH) 2019 showed the following
orders:
-An order dated 11/9/18, for nutritious Juice (a calorie rich, vitamin and protein
enhanced juice drink), six ounces with meals;
-An order dated 11/11/16, for regular diet with regular liquids.
Record review of the resident’s vital sign charting showed the following:
-On 1/16/19, the resident weighed 185.2 pounds.
Record review of the resident’s progress notes dated 3/22/19, at 12:12 P.M., showed the RD
noted resident at 180.2 pounds with a six pound loss in one month, 10.1 pound loss in 3
months, and 18.7 pound loss in 6 months. Further loss is undesired. The RD recommended to
change Nutritious Juice to 90 ml Med Pass Supplement twice daily. Monitor for weight
stabilization.
Record review of the resident’s Order Summary Report showed no new orders were entered to
indicate the RD’s recommendations were followed.
Record review of the resident’s quarterly MDS, dated [DATE], showed the following:
-Cognition severely impaired;
-Needs limited assistance with activities;
-Staff provides guided assistance and one person physical assistance with eating.
Record review of the resident’s care plan, last updated 4/17/19, showed:
-At risk for weight loss related to cognitive deficit;
-Staff was to honor food preferences, provide diet as ordered;
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265188

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

SPRING VALLEY HEALTH & REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

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 – Some

(continued… from page 35)
-Resident to go to restorative dining;
-Staff to review weights and notify the physician and responsible party of a significant
weight change.
Record review of the resident’s vital sign charting showed on 4/18/19 the resident weighed
177.4 pounds.
Record review of the resident’s progress notes dated 4/20/19, at 8:21 A.M., showed a note
by the RD that resident is 177.4 pounds with a loss from 203.5 pounds since October.
Further loss is undesired. The RD recommended Nutritious Juice changed to 90 ml Med Pass
Supplement three times daily to mitigate (make less severe) further weight change. Monitor
weight pattern, intake, and skin.
Record review of the resident’s Order Summary Report showed no new orders were entered to
indicate the RD’s recommendations were followed.
3. Record review of Resident #242’s face sheet showed the following:
-Admission on 2/20/19;
-[DIAGNOSES REDACTED].
Record review of the resident’s vital signs showed the following:
-On 2/20/19, the resident weighed 96.1 pounds;
-On 2/28/19, the resident weighted 94.3 pounds.
Record review of the resident’s care plan, last updated 3/5/19, showed:
-Required tube feeding related to dysphagia (difficulty swallowing);
-Elevate the head of the bed 45 degrees during and for thirty minutes after tube feeding;
-Staff to check for tube placement and residual (left over) volume per facility protocol
and record;
-RD to evaluate quarterly and as needed. Monitor caloric intake, estimate needs, and make
recommendations for changes to tube feeding as needed;
-Speech Therapy evaluation and treatment as ordered.
Record review of the resident’s vital signs showed:
-On 3/14/19, the resident weighed 91.7 pounds.
Record review of the resident’s 30-day Scheduled Assessment MDS, dated [DATE], showed:
-Cognition severely impaired;
-Needs extensive physical assist with all Activities of Daily Living (ADLs);
-Had a feeding tube and received 51% or more of daily caloric intake through the tube.
Record review of the resident’s vital signs showed:
-On 3/28/19, the resident weighed 89.5 pounds.
Record review of the resident’s progress motes dated 3/29/19, at 7:45 P.M., showed the RD
noted resident is at 89.5 pounds with a loss from 96.1 pounds in one month. Further loss
is undesired. Receives [MEDICATION NAME] 1.5 Calorie at 48 ml/hr until 960 ml infused with
42 ml/hour auto flush. Recommended changing tube feeding to [MEDICATION NAME] 1.5 Calorie
at 50 ml/hr until 1000 ml infused with 42/ml hour auto flush. New regimen would provide
1500 calories, 63.8 g protein, and 1900 ml fluid per day.
Record review of the resident’s vital signs showed the following:
-On 4/11/19, the resident weighed 84.9 pounds.
Record review of resident’s hospital records titled Nutrition Focused Physical
Exam-Summary, dated 4/13/19 at 10:28 A.M., showed:
-Dietitian assessment of severe protein-calorie;
-Severe fat loss;
-Muscle wasting assessment showed severe;
-Weight loss greater than 7.5% in three months (severe).
Record Review of the resident’s hospital notes dated 4/13/19, at 11:03 A.M., showed the
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265188

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

SPRING VALLEY HEALTH & REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

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 – Some

(continued… from page 36)
resident’s family member told the nurse that the facility had only been feeding the
resident 50 ml every 12 hours. The family member had a picture of the tube feeding that
was labeled open 3/31 and the photograph was taken on 4/3 with only about 400 ml missing
from the bottle.
Record review of the resident’s Order Recap Report, dated 4/3/19, showed an order for
[REDACTED].
5. During an interview on 5/6/19, at 2:05 P.M., RN K said tube feeding is expected to run
the directed amount of time. The RD made recommendations to increase tube feeding. The RD
recommendations were put in place immediately for Resident #242. RN K said it felt like
the amount should have been raised a little more. The RD that is currently contracted has
never been in the facility. The Director of Nursing (DON) emails the RD with issues
regarding tube feedings. Risk Management meetings are on Wednesdays to discuss weight
loss, antibiotics, falls, or anything of concern. If someone has weight loss the unit
managers usually tell the doctors.
6. During an interview on 5/07/19, at 11:05 P.M., the Director of Nursing said the
following:
-Staff should change out the resident’s Kangaroo bag at least every 48 hours and each
nurse shift should check the tube feeding and document on the amount of tube feeding
administered;
-The administration record should prompt nurses on every shift about the tube feeding
orders.
7. During an interview on 5/07/19, at 1:20 P.M., the facility medical director said the
following:
-The facility should notify a resident’s physician of any dietary recommendations made the
RD;
-The facility staff should administer tube feeding to a resident as ordered.
MO 938 and MO 975

F 0693

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Ensure that feeding tubes are not used unless there is a medical reason and the
resident agrees; and provide appropriate care for a resident with a feeding tube.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview, and record review, the facility failed to follow
physician’s orders or dietitian recommendations for one resident (Resident #236) with a
gastric/enteral feeding tube (a tube inserted into the abdomen that delivers nutrition
directly to the stomach). A sample of 32 residents was selected for review in a facility
with a census of 142.
Record review of the facility’s policy titled, Tube Feeding: Continuous Tube Feeding,
dated (MONTH) (YEAR), showed the following:
-Purpose to provide nourishment to the resident who is unable to obtain nourishment
orally;
-Procedure: Verify the physician order for [REDACTED].>-If intermittent feeding,
disconnect tube feeding bag when not in use and cap end.
1. Record review of Resident #236’s admission record (face sheet) showed resident admitted
on [DATE] from the hospital.
Record review of the resident’s (MONTH) 2019 medication review report showed the following

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265188

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

SPRING VALLEY HEALTH & REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

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 0693

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 37)
physician orders dated 4/11/19:
-Regular diet, mechanical soft texture;
-Flush enteral tube with 30 milliliters (ml) of water pre/post medication administration
and 5-10 ml between each medication;
-Every shift, nurse to check feeding tube residual volume;
-One time a day intermittent pump enteral feeding: Formula Glucerna 1.5 at 60 ml/hour (hr)
until 1200 ml infused with 60 ml/hr autoflush of water. (The resident’s enteral pump
feeding for 20 out of every 24 hours at 60 ml/hr to equal 1200 ml.)
Record review of the resident’s care plan, dated 4/11/19, showed the following:
-Resident requires tube feeding related to dysphagia (difficulty or discomfort in
swallowing);
-The resident needs the head of bed elevated 45 degrees during and thirty minutes after
tube feed;
-Staff to check for tube placement and gastric contents/residual volume per facility
protocol and record;
-Speech therapy evaluate and treat;
-Resident has an activities of daily living (ADL – dressing, grooming, bathing, eating,
and toileting) self-care performance deficit related to [MEDICAL CONDITION] (paralysis of
one side of the body) and stroke diagnoses;
-Resident has a communication problem related to [MEDICAL CONDITION] (loss of the ability
to produce and/or comprehend language, due to injury to brain areas);
-Staff to anticipate and meet needs;
-Resident is able to nod head yes or no.
Record review of the resident’s admission nurse note dated 4/12/19, at 9:11 A.M., showed
the following:
-Late entry for 4/11/19 at 11:40 P.M.;
-Resident arrived from the hospital;
-admission orders [REDACTED]
-Resident is non-verbal, but is able to follow conversation and make needs known by
nodding or shaking head;
-Resident has PEG (feeding) tube with tube feeding of Glucerna 1.5 hung and started at 60
ml/hour and water flushes as per orders.
Record review of the resident’s (MONTH) 2019 treatment administration record (TAR) showed
the following:
-Order dated 4/11/19, for every shift to check peg tube residual volume (aspiration of
stomach contents to determine amount of liquid remaining in stomach);
-Nurses to initial three times per day at 6:30 A.M., 2:30 P.M., and 10:30 P.M.;
-Nurses failed to document the residual checks on 4/13/19, 4/15/19, 4/17/19 at 2:30 P.M.,
4/25/19 at 2:30 P.M., and 4/28/19 at 6:30 A.M.
Record review of the resident’s (MONTH) 2019 TAR for (MONTH) 2019 showed the following:
-Order dated 4/12/19, for one time a day intermittent pump enteral feeding: formula,
Glucerna 1.5 at 60 ml/hr until 1200 ml infused with 60 ml/hr autoflush;
-Nurses to initial daily at 7:00 P.M. (the order contains no stop time);
-Nurses failed to document the administration of the resident’s enteral feedings on
4/13/19, 4/15/19 through 4/17/19, 4/25/19, and 4/29/19.
Record review of the resident’s admission Minimum Data Set (MDS – a comprehensive
assessment tool completed by facility staff), dated 4/18/19, showed the following:
-Severe cognitive impairment;
-Disorganized thinking, behavior present, fluctuates (comes and goes);
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265188

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

SPRING VALLEY HEALTH & REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

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 0693

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 38)
-Required extensive assistance of two or more staff with bed mobility;
-Required extensive assistance of one staff with transfers, dressing, eating, toileting,
and personal hygiene;
-Functional limitation in range of motion, upper extremity and lower extremity impairment
on one side;
-[DIAGNOSES REDACTED].
-Resident has feeding tube and consumes mechanically altered diet for nutritional needs;
-Receives physical therapy (PT), occupational therapy (OT), and speech therapy (ST), five
times per week each.
Record review of the resident’s nutritional assessment, dated 4/18/19, completed by the
dietitian, showed the following:
-Diet order of mechanical soft and Glucerna 1.5 calorie at 60 ml/hr until 1200 ml infused
with 60 ml/hr autoflush;
-No known food allergy;
-Monitor intake;
-Resident receives tube feeding and oral diet;
-No evidence of skin breakdown;
-Regimen is supportive of needs, but would change tube feeding to Glucerna 1.5 240 ml
bolus three times per day after meals if consumes less than 50 % of meals, Glucerna 1.5 ml
at 60 ml/hr from 10:00 P.M. until 6:00 A.M. (480 ml infused), flush feeding tube with 200
ml of water every four hours. New regime to allow for increased oral intake if resident is
accepting.
Observation on 4/24/19, at 3:15 P.M., showed the following:
-The resident lay awake on the bed on his/her back;
-A full pre-filled bottle of Glucerna 1.5 (a high calorie nutritional formula) hung in the
resident’s room with approximately 1200 ml remaining in the bottle, dated 4/23/19 at 7:00
P.M. (20 hours prior), with the tubing inserted into the bottle, but not attached to the
resident;
-The tube feeding pump was turned off;
-A full bag of water hung in the resident’s room, undated and not attached up to the
resident.
(A bottle of 1200 ml running at 60 ml/hr, hung at 7:00 P.M., should have completely
infused in 20 hours.)
Observation on 4/26/19, at 10:50 A.M., showed the following:
-A bottle of Glucerna 1.5 hung in the resident’s room with approximately 525 ml remaining
in the bottle, dated 4/23/19 at 7:00 P.M. (3 days prior) with tubing inserted into bottle,
but not hooked up to the resident;
-The tube feeding pump was turned off;
-A bag of water containing approximately 500 ml remaining in the bag hung in the
resident’s room, dated 4/25/19 at 7:00 P.M., and not hooked up to the resident.
(A bottle containing 1200 ml running at 60 ml/hr, hung at 7:00 P.M. on 4/23/19 should have
completely infused in 20 hours on 4/24/19 at approximately 3:00 P.M.)
Observation in the resident’s room on 4/29/19, at 1:25 P.M., showed the following:
-A bottle of Glucerna hung in the resident’s room with approximately 550 ml remaining in
the bottle, dated 4/28/19 and no time, with tubing inserted into the bottle;
-The tube feeding pump was turned off;
-A bag of water hung in the resident’s room with approximately 400 ml remaining in the
bag, dated 4/28/19.
(A bottle of 1200 ml running at 60 ml/hr, hung at 7:00 P.M., should have completely
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265188

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

SPRING VALLEY HEALTH & REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

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 0693

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 39)
infused in 20 hours.)
-The resident sat in the hallway.
Observation on 5/02/19 showed the following:
-At 8:20 A.M., a bottle of Glucerna hung in the resident’s room with approximately 550 ml
remaining in the bag, dated 4/30/19 at 9:30 P.M., with tubing inserted;
-The tube feeding pump was turned off;
-A bag of water hung in the resident’s room with approximately 400 ml remaining in the
bag, dated 4/29/19 at 7:00 P.M.;
-At 10:30 A.M., the resident lay in bed, the tube feeding remained disconnected and turned
off.
(A bottle of 1200 ml running at 60 ml/hr, hung on 4/30/19 at 9:30 P.M., should have
completely infused in 20 hours on 5/01/19.)
During an interview on 5/02/19, at 10:35 A.M., Licensed Practical Nurse (LPN) MM said the
following:
-The day shift nurses do not administer the resident’s tube feeding, it is evening or
night shift’s responsibility;
-The nurse said the resident only gets one medication and 30 ml of water thru the feeding
tube during the day.
During an interview on 5/02/19, at 10:45 A.M., Registered Nurse/Unit Manager (RN) K said
the following:
-He/she does not know the resident’s tube feeding orders;
-He/she does not know if the dietitian sees the resident;
-If the RD makes a recommendation, RN K sends it to the Director of Nursing (DON).
During an interview on 5/02/19, at 11:24 A.M., the DON said the following:
-The resident’s feeding tube would need to run for 20 out of 24 hours to administer the
ordered amount;
-Dietitian recommendations first go to the dietary manager, then to the DON;
-If the resident needs a new diet or tube feeding order, the DON contacts the physician.
During an interview on 5/02/19, at 12:30 P.M., the dietary manager (DM) said the
following:
-The facility previously had a full time RD, who left in (MONTH) 2019;
-Since the beginning of the year, the dietitian reviews the resident’s charts remotely and
does not generally come to the facility to see residents.
During an interview on 5/06/19, at 3:55 P.M., RN K said the following:
-The resident’s tube feeding orders came from the hospital;
-If the RD makes a recommendation, RN K generally finds the recommendations when auditing
the progress notes;
-He/she unaware of any recommendations to change the resident’s tube feedings;
-He/she does not know the resident’s current tube feeding orders;
-He/she expects nurses to replace bottles of Glucerna and bags for water at least every 24
hours;
-He/she said she does not follow up to ensure nurses are giving the residents their
ordered tube feedings;
-After reviewing the resident’s current orders, RN K said the resident should be hooked up
to the tube feeding all the time except for 4 hours during the day for meals and therapy.
During an interview on 5/07/19, at 11:05 P.M., the DON said the following:
-Staff should change out the resident’s Kangaroo bag at least every 48 hours and each
nurse shift should check the tube feeding and document on the amount of tube feeding
administered;
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265188

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

SPRING VALLEY HEALTH & REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

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 0693

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 40)
-The administration record should prompt nurses on every shift about the tube feeding
orders.
During an interview on 5/07/19, at 1:20 P.M., the facility medical director said the
following:
-The facility should notify a resident’s physician of any dietary recommendations made the
RD;
-The facility staff should administer tube feeding to a resident as ordered.

F 0695

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Provide safe and appropriate respiratory care for a resident when needed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview, and record review, the facility failed to ensure staff
changed oxygen equipment per professional standards for three residents (Resident #47,
#87, and #112) out of a sample of 32 residents selected for review. The facility had a
census of 142.
Record review of the facility’s policy titled Oxygen Administration and Storage, dated
01/01/14, showed the following:
-Tubing should be changed weekly;
-Nasal cannula tubing may need to be changed more frequently.
1. Record review of Resident #47’s face sheet (a document that gives a resident’s
information at a quick glance) showed the following:
-admitted to the facility on [DATE];
-[DIAGNOSES REDACTED]. This leads to a limitation of the flow of air to and from the lungs
causing shortness of breath.), [MEDICAL CONDITION] disorder, and generalized anxiety
disorder.
Record review of the resident’s quarterly assessment Minimum Data Set (MDS – a federally
mandated comprehensive assessment instrument completed by facility staff), dated 02/20/19,
showed the following information:
-Cognitively intact;
-Oxygen therapy.
Record review of the resident’s care plan, revised on 03/09/19, showed staff did not care
plan the use of oxygen.
Record review of the resident’s Physician order [REDACTED].
-2 liters of oxygen per minute via nasal cannula for [MEDICAL CONDITION], start date
08/13/18;
-No order was present indicating the frequency staff should replace the nasal
cannula/tubing.
Record review of the resident’s treatment administration record (TAR), dated 05/07/19, did
not show a scheduled change in oxygen tubing.
Observation on 05/03/19, at 11:28 A.M., showed Resident #47 receiving oxygen. The tubing
was dated 04/03/19. CNA C entered his/her room and Resident #47 asked the aide to change
his/her tubing.
During an interview on 05/03/19, at 11:28 A.M., Resident #47 said his/her tubing has not
been changed since 04/03/19.
2 .Record review of Resident #87’s face sheet (a document that gives a resident’s
information at a quick glance) showed the resident readmitted to the facility on [DATE].

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265188

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

SPRING VALLEY HEALTH & REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

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 0695

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 41)
The resident’s [DIAGNOSES REDACTED].
Record review of the resident’s care plan, revised on 02/13/19, staff did not care plan
the use of oxygen.
Record review of the resident’s 60 day MDS, dated [DATE], showed the following
information:
-Cognitively intact;
-Oxygen therapy.
Record review of the resident’s POS, dated 05/07/19, showed the following:
-Two liters of oxygen per minute via nasal cannula for [MEDICAL CONDITION], start date
08/23/18;
-No order was present indicating the frequency staff should replace the nasal
cannula/tubing.
Observation on 04/25/19, at 03:48 P.M., showed the resident in bed, receiving 2.5 liters
oxygen, via nasal cannula. No date was present on the oxygen tubing.
Observation on 05/03/19, at 02:05 P.M., showed the the resident in bed, receiving 2.5
liters oxygen, via nasal cannula. No date was present on the oxygen tubing.
During an interview on 05/03/19, at 2:05 P.M., the resident said he/she tells the aide
whenever he/she needs it changed. He/she states staff will change it every month or two.
The last time it was changed was about three weeks ago.
Record review of the resident’s TAR, dated 05/07/19, showed no scheduled change in oxygen
tubing.
3. Record review of Resident #112’s face sheet showed the following:
-admitted on [DATE];
-[DIAGNOSES REDACTED].
Record review of the resident’s 14 day MDS, dated [DATE], showed:
-Cognitively intact;
-Requires extensive assist with transfers, activities of daily living (ADLs-dressing,
grooming, bathing, eating, and toileting) and locomotion (movement from one place to
another);
-Resident receives oxygen and [MEDICAL CONDITION] (an opening through the neck into the
windpipe to provide and airway and to remove secretions).
Record review of the resident’s POS showed a current order for oxygen at three liters per
cannula.
Observation on 4/26/19, at 9:30 A.M., showed the resident’s oxygen tubing had no date
written on it. The resident’s oxygen humidifier bottle was empty and had no date on it.
During an interview on 04/26/19, at 9:30 A.M., the resident said the oxygen tubing gets
changed about every month. It was last changed approximately two weeks ago.
4. During an interview on 05/02/19, at 10:37 A.M., Registered Nurse (RN) D said night
nursing staff change the oxygen tubing.
5. During an interview on 05/03/19, at 9:00 A.M., the Director of Nursing (DON) said there
is no documentation of staff changing oxygen tubing. The night nurses change the tubing
once a wk.
6. During an interview on 05/03/19, at 11:07 A.M., CNA C said he/she does not know when
oxygen tubing needs to be changed, but he/she will change the tubing if a resident
requests it.
MO 938 and MO 233

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265188

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

SPRING VALLEY HEALTH & REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

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 0695

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

F 0697

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Provide safe, appropriate pain management for a resident who requires such services.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observations, record review, and interview, the facility failed to provide pain
medications to one resident (Resident #95) in a timely fashion and failed to ensure pain
medications were on-hand for one resident (Resident #70). A sample of 32 sampled residents
was selected for review. The facility census was 142.
Record review of the facility’s policy titled Pain Management Guidelines, revised (MONTH)
(YEAR), showed the following:
-Purpose to attain and maintain the highest practicable level of well-being and to prevent
or manage pain, the facility to the fullest extent possible will: Recognize when a
resident is experiencing pain, identify circumstances when pain can be anticipated, and
evaluate existing pain and cause;
-Upon admission, residents will be assessed for pain by using the nursing admission
assessment form;
-Residents will be screened for pain by using the assessment form quarterly, annually, and
with significant change and/or new onset of pain;
-Pain intensity and pain relief will be assessed prior to administration of medication and
post pain medication administration to assess for effectiveness of pain medication;
-Those who cannot report pain may present with non-specific signs such as grimacing,
increased confusion, restlessness, etc. To distinguish between pain and other signs of
distress it is imperative to assess resident to confirm signs and symptoms are indeed
related to pain;
-If any resident reports inadequate pain control, residents will have an assessment
performed;
-Following the pain evaluation, notify the physician of the findings;
-Each resident identified for pain will have a pain management care plan, The care plan
will have individualized interventions related to the resident’s individualized control of
pain management;
-The nurse will implement a Medication Administration Record [REDACTED]
-The nurse when administering PRN pain medication, will record the drug administration and
the following on the MAR:
-Pain level prior to the administration of the pain medication administration;
-Pharmacological interventions attempted:
-Non-pharmacological interventions attempted;
-Follow up observation post intervention to determine the effectiveness of PRN pain
interventions. If resident is asleep or resting, document as an observation;
-PRN pain medications may be reviewed for the need for routinely scheduled orders.
1. Record review of Resident #95’s admission record showed the following:
-admitted to the facility on [DATE] from the hospital;
-[DIAGNOSES REDACTED]. infection), reduced mobility, and adult failure to thrive.
Record review of the resident’s physician order [REDACTED].
-Staff to complete pain evaluation every day shift for monitoring of the resident’s pain
level;
-Staff to administer [MEDICATION NAME] ([MEDICATION NAME]/[MEDICATION NAME], a narcotic
pain medication) tablet 10/325 milligrams (mg), give one tablet every six hours as needed
for pain;
-Staff to apply negative pressure wound therapy 150 millimeters (mm)/mercury (hg) every
day shift Monday and Thursday for wound care.

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265188

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

SPRING VALLEY HEALTH & REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

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 0697

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 43)
Record review of the resident’s nursing admission screening/history, signed 3/01/19,
showed the following:
-admitted from the hospital;
-Oriented to person, place, and time;
-Reason for admission was wound care and intravenous (IV) antibiotic therapy;
-Resident has pain rated as a ‘9’ on the numeric rating scale with 1=mild pain to 10=worst
possible pain. Location of pain is bilateral lower extremities and wounds (pressure
ulcers).
Record review of the resident’s care plan, dated 3/01/19, showed the following:
-Has chronic pain related to chronic physical disability, [MEDICAL CONDITION], and wounds;
-Staff to administer [MEDICATION NAME] ([MEDICATION NAME]) as per orders;
-Anticipate the residents need for pain relief and respond immediately to any complaint of
pain.
Record review of the resident’s (MONTH) 2019 Registered Nurse (RN)/Licensed Practical
Nurse (LPN) Medication Administration Record [REDACTED].M., staff documented
administration of one dose of [MEDICATION NAME] 10/325 mg for complaints of pain rated as
an ‘8’ with effective results.
Record review of the resident’s activities progress note dated 3/01/19, at 8:59 A.M.,
completed by the activity assistant showed the following:
-The resident said he/she would like a pain pill;
-The resident said when he/she asked the nurse, the nurse said no and was very rude;
-The activity assistant spoke to the resident’s nurse and then returned to the resident’s
room and informed the resident is was too early for a pain pill;
-The resident became angry and said he/she had not yet asked for a pain pill;
-The resident then pulled the blanket over his/her head.
(Nursing staff did not document about the resident’s request for pain medication).
Record review of the resident’s (MONTH) 2019 RN/LPN MAR indicated [REDACTED]
-On 3/02/19, nurses did not document administration of any PRN [MEDICATION NAME] for pain
to the resident;
-On 3/02/19, nurses did not document a pain assessment for the resident.
Record review of the resident’s (MONTH) 2019 MAR indicated [REDACTED]
-On 3/02/19, at 6:30 A.M., a certified medication technician (CMT) documented the
resident’s pain level at a ‘7’;
-Staff did not document any pain interventions.
Record review of the resident’s physician progress notes [REDACTED].M., showed the
following:
-physician’s orders [REDACTED].
Record review of the facility’s narcotic receipt packing slip, signed on 3/05/19, showed
the following:
-The facility received a card of 30 tablets of [MEDICATION NAME] 10/325 mg on 3/05/19 for
the resident;
Record review of the resident’s admission minimum data set (MDS – a federally mandated
assessment tool completed by facility staff), dated 3/07/19, showed the following:
-Severe cognitive impairment;
-Inattention, behavior present, fluctuates (comes and goes);
-Experiences delusions;
-Exhibits behavioral symptoms toward others;
-Staff administer pain medications as needed (PRN);
-Staff did not utilize non-medication interventions for pain;
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265188

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

SPRING VALLEY HEALTH & REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

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 0697

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 44)
-Pain is frequent and rated as a ‘7’.
Record review of the resident’s (MONTH) 2019 MAR indicated [REDACTED]
-On 3/08/19 at 6:30 A.M., a CMT documented the resident’s pain at a 7;
-Staff did not document any pain interventions related to the resident’s complaint of
pain.
Record review of the skin observation tool dated 3/08/19, at 8:49 A.M., completed by the
facility wound nurse, showed the following:
-Resident frequently complains of discomfort with wounds;
-Staff did not document any pain interventions related to the resident’s complaint of
pain.
Record review of the resident’s (MONTH) 2019 RN/LPN MAR indicated [REDACTED]
-On 3/08/19, the resident complained of pain at 6:30 A.M. and at 8:49 A.M.;
-On 3/08/19, the nurse administered a pain pill ([MEDICATION NAME] 10/325 mg) to the
resident 9:40 P.M. (over 15 hours after the first complaint of pain.
Record review of the skin observation tool dated 3/15/19, at 8:49 A.M., completed by the
facility wound nurse, showed the following:
-Resident frequently complains of discomfort with wounds;
-Staff did not document any pain interventions related to the resident’s complaints of
discomfort.
Record review of the resident’s (MONTH) 2019 RN/LPN MAR indicated [REDACTED]
-On 3/15/19, the resident complained of discomfort at 8:49 A.M.’
-Staff administered pain medication at 6:21 P.M. for resident’s for complaints of pain
rated as a ‘7’ with effective results (a nine hour delay in medication administration).
Record review of the resident’s nurse progress note dated 3/22/19, at 3:15 P.M., showed
the nurse entered the resident’s room to let him/her know the nurse was working on getting
his/her pain medications and the facility had notified the resident’s physician of the
need to fax a script to the pharmacy. The resident became upset about it and stated he/she
just did not understand. The nurse attempted to explain to the resident that sometimes the
physicians do not get things done in a timely fashion and the resident acknowledged
understanding. The nurse did not document any other pain interventions for the resident.
Record review of the resident’s (MONTH) 2019 RN/LPN MAR indicated [REDACTED]
-On 3/22/19, at 7:11 P.M., the resident rated his/her pain level as an ‘8’ and staff
administered a pain pill, nearly 4 hours after the resident’s request for pain medication.
Record review of the resident’s nurse progress notes, dated 3/26/19 at 5:26 A.M., showed
the following:
-The resident requested his/her pain medication early;
-The nurse instructed the resident that the pain medication is to be given every six hours
only;
-The nurse did not document any other attempted pain intervention.
Record review of the resident’s (MONTH) 2019 RN/LPN MAR indicated [REDACTED]
-On 3/26/19 at 8:45 P.M., the resident rated his/her pain as a 7 and staff administered a
pain pill ([MEDICATION NAME]), 15 hours after the resident’s original request for pain
medication;
Record review of the resident’s skin observation tool dated of 3/28/19, at 8:56 A.M.,
completed by the facility wound nurse, showed the following:
-Resident states he/she always hurts;
-The wound nurse did not document any other attempted pain interventions or address the
resident’s pain.
Record review of the resident’s 30-day minimum data set (MDS), dated [DATE], showed the
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265188

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

SPRING VALLEY HEALTH & REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

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 0697

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 45)
following:
-Resident admitted to the facility on [DATE];
-Moderately impaired cognitive ability;
-Resident takes as needed pain medication for frequent pain, rates pain a 6 on a scale of
0-10.
Record review of the resident’s family nurse practitioner (FNP) progress note, dated
4/18/19, showed the following:
-Resident denies any specific complaints. Pain is controlled. Resident continues to
tolerate the [DEVICE];
-Encouraged offloading to his/her sacral wound as the resident has been up in a wheelchair
10 or more hours per day for the past 2 weeks;
Observation and interview on 4/25/19, at 11:15 A.M., showed the following:
-Registered Nurse (RN) Q entered the resident’s room to complete wound care;
-During the dressing change, the resident cried out and said, It hurts! and the wound
nurse replied, I’m sure it does.
-The resident rated his/her pain as an 8 on a scale of 1-10.
-During the dressing change, the resident made a grunting noise. The nurse asked the
resident if he/she was okay and the resident responded he/she was hurting. The nurse
responded by telling the resident, You are being really patient with me and I appreciate
it.
(The nurse did not stop to administer pain medication to the resident and did not pretreat
the resident for the pain.)
During an interview on 4/26/19, at 9:50 A.M., Certified Nurse Assistant (CNA) P said the
resident complain of pain all the time, once the resident wakes up, he/she is in constant
pain.
During an interview on 4/26/19, at 10:55 A.M., the RN K said the facility has an issue
with having pain medications available for the residents.
During an interview on 4/26/19, at 1:22 P.M., the resident’s family nurse practitioner
(FNP) said the following:
-The FNP said the resident’s pain level is no different than normal for the resident;
-The FNP said he/she did not know if the resident was experiencing pain to the pressure
ulcer, he/she would have to ask the resident.
2. Record review of Resident #70’s admission MDS, dated [DATE], showed the following:
-admitted to the facility on [DATE] from the hospital;
-Resident is cognitively intact;
-Resident has [DIAGNOSES REDACTED].
-Resident takes scheduled and as needed (PRN) pain medications;
-Resident experiences frequent pain that makes sleep difficult;
-Resident rates pain as a ‘5’ (on a scale of 0=no pain to 10=most severe pain).
Record review of the resident’s nurse’s progress notes dated 3/15/19, at 12:30 P.M.,
showed a nurse documented the following:
-Contacted the resident’s physician related to resident complaints of [MEDICAL CONDITION]
(weakness, numbness, and pain from nerve damage) and pain and requested that [MEDICATION
NAME] (anticonvulsant) order be clarified and changed back to the dosage the resident was
taking at home, as well as request to increase the resident’s pain medication;
-The physician gave orders to increase the resident’s [MEDICATION NAME] to 800 mg four
times a day and gave an order for [REDACTED].>-The nurse faxed the orders to the
pharmacy.
Record view of the resident’s medication review report showed the following current
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265188

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

SPRING VALLEY HEALTH & REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

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 0697

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 46)
orders:
-Order dated 3/15/19 for [MEDICATION NAME] 15 mg, give 0.5 tablet (to equal 7.5 mg) by
mouth every four hours as needed for diabetic [MEDICAL CONDITION] or pain;
-Order dated 3/15/19 for [MEDICATION NAME] 800 mg, give one tablet by mouth four times a
day related to diabetes with diabetic [MEDICAL CONDITION].
Record review of the resident’s nurse progress note dated 3/16/19, at 10:39 A.M., showed a
nurse documented the following:
-Off-going nurse reported that he/she had called the pharmacy to relay new orders of an
increase dosage in the resident’s PRN [MEDICATION NAME] as well as requested to pull the
medication from the emergency kit at the facility;
-The pharmacy denied the facility’s request;
-The nurse placed two calls to the resident’s physician and left messages for return call
regarding the need for pharmacy communication;
-The nurse provided the resident with a PRN Tylenol and the medication was determined to
be effective as the resident is sleeping.
Record review of the resident’s nurse progress notes dated 3/16/2019, at 10:04 P.M.,
showed the following:
-The nurse went into the resident’s room to give his/her medications;
-The nurse had to wake the resident up to give the medications and check the resident’s
blood sugar;
-The resident did not complain of pain to the nurse all shift;
-The resident asked if his/her pain pills were at the facility yet, and the nurse told the
resident they were not;
-The nurse explained to the resident that there is nothing the nurse can do to further
help the situation of pain pills;
-The pharmacy will not dispense the resident’s pain medications because the facility
received 60 pills the previous day and then the physician discontinued that order upon
resident request, because he/she wanted a higher dosage of pain medication;
-The resident has slept all shift other than when he/she had to be woke up for medications
and blood sugar checks along with insulin administration;
-The nurse notified the DON;
-The nurse spoke with the resident’s family member who stated he/she would be at this
facility in the morning to come up with a solution to correct the problem of pain
medications.
Record review of the resident’s care plan, revised on 3/21/19, showed the following:
-Resident has chronic pain related to arthritis and diabetic [MEDICAL CONDITION];
-Staff to administer pain medications as per orders;
-Evaluate the effectiveness of pain interventions, review for compliance, alleviation of
symptoms, dosing schedules and resident satisfaction with results, impact on functional
ability and impact on cognition;
-Identify and record previous pain history and management of that pain and impact on
function. Identify previous response to [MEDICATION NAME] including pain relief, side
effects and impact on function;
-Notify physician if interventions are unsuccessful or if current complaint is a
significant change from the resident’s past experience of pain.
Record review of the resident’s nurse progress notes dated 4/02/19, at 9:25 P.M., showed
the following:
-A nurse notified the pharmacy of the need for the resident’s [MEDICATION NAME] 7.5 mg;
-The pharmacy said they sent out the medication on Wednesday and the facility should still
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265188

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

SPRING VALLEY HEALTH & REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

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 0697

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 47)
have a supply for the resident;
-The nurse informed the pharmacy, the facility did not have the medication and would need
to have the medication refilled;
-The pharmacy said the DON would need to call and give authorization of the medication to
be sent;
-The nurse called the DON and notified of the situation.
Record review of the resident’s nurse progress notes dated 4/03/19, at 12:34 A.M., showed
the following:
-The nurse placed a call to the pharmacy in regards to the medication not available in
emergency kit;
-The pharmacy said the medication was out for delivery;
-Notified the resident of the situation;
-Call placed to the physician;
-Resident told the nurse to ask the physician for a temporary order for another pain
medication because the nurses did so in the past.
Record review of the resident’s progress notes dated 4/03/19, at 8:09 A.M., showed a nurse
documented the following:
-Received a physician’s orders [REDACTED]. for [MEDICATION NAME] 5 mg, give one tablet
every four hours as needed for pain, and discontinue this order when the resident’s
regular supply of pain medication is available from the pharmacy;
-At 6:18 A.M., nurse administered the [MEDICATION NAME] 5 mg for resident complaint of 4
out of 1-10 pain scale.
Record review of the resident’s progress notes dated 4/03/19, at 10:56 A.M., showed a
nurse documented the following:
-The facility restarted the resident’s order for [MEDICATION NAME] 15 mg, give 0.5 tablet
(to equal 7.5 mg) and the nurse administered a dose of the medication.
During an interview on 4/24/19, at 3:30 P.M., the resident said the following:
-The resident states he/she has difficulty getting pain medications when needed;
-The resident said at times the facility runs out of pain medications for the residents;
-The resident said other times, the nurses are slow to deliver the pain medications;
-The resident said he/she frequently waits an hour for pain medication after requesting
the medicine.
Record review of the resident’s (MONTH) 2019 RN/LPN MAR indicated [REDACTED]
-On 4/25/19, at 1:30 A.M., a nurse documented the resident’s pain level as a ‘4’ and
administered [MEDICATION NAME] 15 mg, 0.5 tablet;
-On 4/25/19 at 5:30 A.M. a nurse documented the resident’s pain level as a ‘4’ and
administered [MEDICATION NAME] 15 mg, 0.5 tablet;
-Staff did not document administration of any additional doses of [MEDICATION NAME] 15 mg,
0.5 tablet on 4/25/19.
Record review of the resident’s (MONTH) 2019 MAR indicated [REDACTED]
-On 4/25/19, staff documented a pain evaluation at 6:30 A.M., showing the resident’s pain
level as a ‘3’;
-On 4/25/19, staff did not document any interventions.
Record review of the resident’s progress notes dated 4/25/19, at 3:36 P.M., showed LPN X
entered the following order:
-[MEDICATION NAME]/[MEDICATION NAME] tablet 5/325/ milligrams (mg) give one table every 4
hours as needed for pain use order until [MEDICATION NAME] 7.5 mg arrives from pharmacy
then discontinue.
Record review of the resident’s care plan, revised on 4/25/19, showed the following:
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265188

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

SPRING VALLEY HEALTH & REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

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 0697

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 48)
-Resident has potential to have verbally aggressive and manipulative behaviors related to
pain management. Examples include keeping narcotics at bedside, becoming tearful when
he/she is unable to get his/her wishes, and calling a family member to speak to staff when
he/she does not get his/her wishes;
-Staff to give the resident as many choices as possible about care and activities;
-Provide positive feedback for good behavior. Emphasize the positive aspects of
compliance;
-Resident will be compliant with physician orders [REDACTED].
During an interview on 4/25/19, at 4:37 P.M., RN K said the following:
-The resident has had an issue with pain management and pain control;
-A CNA reported that the resident had a bottle of pain pills in his/her room, staff asked
the resident about the medications and the resident said admitted to having the
medication;
-The facility does have an issue with pain medication availability, but when that occurs
the nurses put another medication in place;
-The resident had a bottle of [MEDICATION NAME] 5/325 mg (20 pills) in his/her dresser
with a note dated that family brought the medication into the facility on [DATE];
-The facility does not believe the resident has taken any of the pain pills.
During an interview on 4/26/19, at approximately 12:00 P.M., the resident’s family member
arrived to the resident’s room and said the following:
-He/she did bring the resident a bottle of [MEDICATION NAME] for emergencies to keep in
his/her room, but the resident had not taken any of the pills;
-The family member said he/she brought the medication to the resident because the facility
ran out of the resident’s pain medication and the resident went without medication for 24
hours.
3. During an interview on 4/26/19, at 9:30 A.M., CMT GG, said the following:
-For approximately the past month, the facility has had an issue with running out of pain
medications for the residents;
-The facility is using a different pharmacy a couple months ago and this pharmacy does not
send medications timely when staff order the medications;
Facility staff call the pharmacy and the pharmacy often gives the excuse they are waiting
on the physician’s script;
-Residents are in pain and they need their pain medications;
-Sometimes the nurses have to call the physicians and get an order for [REDACTED].>-The
PRN pain medications are what the facility generally runs out of for the residents.
4. During an interview on 4/26/19, at 10:25 P.M., the Director of Nursing (DON) said the
following:
-The facility has a new pharmacy provider;
-Since the new pharmacy started, the facility has a problem with running out of narcotic
pain medications for the residents;
-The facility has a problem with getting one of the facility physicians to sign narcotic
scripts;
-The physician refuses to sign scripts during the day, he will only sign in the evening
from his home;
-This sometimes results in a delay in the pharmacy sending the resident’s ordered pain
medications;
-This creates a delay of up to 24 hours at times;
-The administrator is aware of the issue with not getting narcotics timely.
5. During an interview on 4/26/19, at 10:55 A.M., the RN K said the following:
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265188

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

SPRING VALLEY HEALTH & REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

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 0697

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 49)
-The RN said the facility has an issue with having pain medications available for the
residents;
-One of the facility physician will only sign scripts one time per day;
-He/she has asked the physician to sign scripts for resident pain medication in the middle
of the day, while the physician is in the facility, and the physician refuses;
-The nurses also run out of medications to use in the emergency kit or do not have certain
medications in the kit;
-Some of the staff/residents have reported that nurses tell them the facility does not
have their pain medications and they will have to wait;
-The RN said she would expect the nurses to treat the resident’s complaints of pain with
ordered medications, or by contacting the physician, or by offering non-pharmacological
interventions.
6. During an interview on 4/26/19, at 11:20 P. M., CNA HH said the facility has difficulty
getting pain medications from the pharmacy, especially for the newly admitted residents.
7. During an interview on 5/07/19, at 1:20 P.M., the medical director said the following:
-He expected the facility to have the ordered pain medications available for the
residents;
-The facility has changed pharmacies three times in the last year and he suspects some of
the nursing staff may not be educated on the medication ordering process.
8. During an interview on 5/07/19, at 3:15 P.M., the facility administrator and DON said
the following:
-They expect medications to be administered as ordered and call physician when needed for
change in order.
MO 966 and MO 354

F 0759

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Ensure medication error rates are not 5 percent or greater.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, record review, and interviews, the facility failed to ensure a
medication error rate of less then 5% when staff made five errors out of 29 opportunities
resulting in a 17% error rate. Staff administered the wrong eye drops for the scheduled
time to one resident (Resident #89) and failed to prime insulin pens for three residents
(Residents #4, #15, and #67) during random medication pass observations. The facility had
a census of 142.
1. Record review of the Resident #89’s (MONTH) 2019 physician order [REDACTED].
-An order dated 4/13/19, for Latanoprost Solution 0.005%; instill one drop in both eyes at
bedtime for [MEDICAL CONDITION];
-An order dated 1/4/19, [MEDICATION NAME] Tears Solution 0.2-0.2-1 % ([MEDICATION
NAME]-Hypromellose-PEG 400); instill two drops in both eyes two times a day for dry eyes;
may use generic artificial tears.
Record review of the resident’s (MONTH) 2019 Medication Administration Record [REDACTED]
-Visine Tears Solution scheduled for 6:00 A.M. and 7:00 P.M. daily;
-Latanoprost Solution scheduled for 8:00 P.M. daily.
Observation and interview on 5/2/19, at 8:12 A.M., showed Certified Medication Technician
(CMT) A picked up a box from the medication cart drawer that [MEDICATION NAME] Tears
Solution, pharmacy labeled for the resident. The CMT told the surveyor he/she did not

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265188

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

SPRING VALLEY HEALTH & REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

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

(continued… from page 50)
administer those eye drops to the resident; the night shift might give those drops. CMT A
washed his/her hands, donned gloves, and instilled one drop of Latanoprost 0.005% solution
into each of the resident’s eyes.
2. According to the manufacturer’s guidelines, a [MEDICATION NAME](fast acting insulin)
pre-filled pen should be primed with each use by expelling two units of insulin prior to
the administration of the ordered units for the dose.
Record review of a facility’s policy and procedure entitled Medication Administration –
Subcutaneous Insulin, dated (MONTH) (YEAR), showed the following:
-Administer subcutaneous (under skin) insulin as ordered and in a safe, accurate and
effective manner;
-When using a pre-filled insulin pen, always perform the safety test before each injection
to ensure that you get an accurate dose:
-Set the dose;
-Hold the pen with the needle pointing upwards;
-Tap the insulin reservoir so that any air bubbles rise up toward the needle
-Press the injection button all the way in; check to see if insulin cones out of the
needle tip. Repeat if necessary; change needles after three failed tests;
-Check that the dose window shows 0 following the safety test.
3. Record of Resident #15’s (MONTH) 2019 POS for (MONTH) 2019 showed an order, dated
3/22/19, for [MEDICATION NAME] Solution (Insulin [MEDICATION NAME]); inject eight units
subcutaneously in the afternoon for diabetes.
Record review of the resident’s (MONTH) 2019 MAR indicated [REDACTED]
-[MEDICATION NAME] Solution, 8 units, scheduled for 12:00 P.M. daily.
Observation and interview on 5/2/19, at 11:57 A.M., showed CMT B performed an AccuCheck
(blood test to determine glucose/sugar level) for the resident. The CMT said the resident
had physician orders [REDACTED]. CMT B removed the cap from the insulin pen, wiped the tip
with an alcohol swab, and attached a disposable needle. Without priming the insulin pen,
CMT B turned the dial on the pen to the 8 indicator mark and administered the insulin to
the resident’s upper right arm.
4. Record review of Resident #67’s (MONTH) 2019 POS showed an order, dated 4/19/19, for
[MEDICATION NAME] (fast acting insulin) [MEDICATION NAME] Solution Cartridge 100 units/ml
(Insulin [MEDICATION NAME]); inject three units subcutaneously with meals related to
diabetes.
Record review of the resident’s [DATE], showed the following:
-[MEDICATION NAME] Solution Cartridge, 3 units, scheduled for 12:00 P.M. daily.
Observation and interview on 5/2/19 at 12:12 P.M., showed CMT B performed an AccuCheck for
Resident #67. The CMT said resident had physician orders [REDACTED]. CMT B removed the cap
from the insulin pen, wiped the tip with an alcohol swab, and attached a disposable
needle. Without priming the pen, CMT B turned the dial on the pen to the 3 indicator mark
and administered the insulin to the resident’s abdomen.
5. Record review Resident #4’s physician’s orders [REDACTED].>-an order for
[REDACTED].>-an order for [REDACTED].
Observation and interview on 5/2/19, at 8:01 A.M., showed CMT R had already performed an
AccuCheck for the resident. The CMT said resident had physician orders [REDACTED]. CMT R
removed the cap from the insulin pen, wiped the tip with an alcohol swab, and attached a
disposable needle. Without priming the pen, CMT R turned the dial on the pen to the 70
indicator mark and administered the insulin to the resident’s abdomen.
6. During an interview on 5/7/19, at 10:35 A.M., CMT L said he/she attended a specialized
class pertaining to insulin administration. At the conclusion of the class, he/she took
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265188

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

SPRING VALLEY HEALTH & REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

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

(continued… from page 51)
both a written and hands-on test to become certified to administer insulin in a nursing
facility. CMT L said he/she spent a day or two with CMT B as orientation at this facility
and received no instructions pertaining to priming insulin pens. CMT L was unaware of the
need to prime an insulin pen.
7. During an interview on 5/7/19, at 10:55 A.M., Licensed Practical Nurse (LPN) M said an
insulin pen should be primed before the first use of the pen, but was not aware of
recommendations to prime with every use.
8. During an interview on 5/7/19, at 3:16 P.M., the Director of Nursing (DON) said nurses
and CMTs should verify that a medication matches the MAR before administering the
medication. The DON said insulin pens should be primed with two units prior to every use.
9. During an interview on 5/2/19, at 8:00 A.M., CMT R said he/she has been at the facility
approximately 3 months and took a two day class for insulin certification.
MO 938, MO 966, MO 354, MO 428 and MO 587

F 0760

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Ensure that residents are free from significant medication errors.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, record review, and interviews, the facility failed to ensure
residents were free of significant medication errors when staff failed to prime insulin
pens for three residents (Residents #4, #15, and #67) during random medication pass
observations. The facility had a census of 142.
According to the manufacturer’s guidelines, a [MEDICATION NAME](rapid acting insulin)
pre-filled pen should be primed with each use by expelling two units of insulin prior to
the administration of the ordered units for the dose.
Record review of a facility’s policy and procedure entitled Medication Administration –
Subcutaneous Insulin, dated (MONTH) (YEAR), showed the following:
-Administer subcutaneous (under the skin) insulin as ordered and in a safe, accurate and
effective manner;
-When using a pre-filled insulin pen, always perform the safety test before each injection
to ensure that an accurate dose:
-Set the dose;
-Hold the pen with the needle pointing upwards;
-Tap the insulin reservoir so that any air bubbles rise up toward the needle;
-Press the injection button all the way in; check to see if insulin cones out of the
needle tip. Repeat if necessary; change needles after three failed tests;
-Check that the dose window shows 0 following the safety test.
1. Record of Resident #15’s (MONTH) 2019 physicians’ order sheet (POS) showed an order,
dated 3/22/19, for [MEDICATION NAME] Solution (Insulin [MEDICATION NAME] – rapid acting
insulin); inject eight units subcutaneously in the afternoon for diabetes.
Record review of the the resident’s (MONTH) 2019 Medication Administration Record
[REDACTED]
-[MEDICATION NAME] Solution (quick acting insulin), 8 units, scheduled for 12:00 P.M.
daily;
-Staff documented administration of the [MEDICATION NAME] Solution, 8 units, daily.
Observation and interview on 5/2/19, at 11:57 A.M., showed Certified Medication Tech (CMT)
B performed an AccuCheck (blood test to determine glucose/sugar level) for the resident.

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265188

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

SPRING VALLEY HEALTH & REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

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

(continued… from page 52)
The CMT said the resident had a physician orders [REDACTED]. CMT B removed the cap from
the insulin pen, wiped the tip with an alcohol swab, and attached a disposable needle.
Without priming the insulin pen, CMT B turned the dial on the pen to the 8 indicator mark
and administered the insulin to the resident’s upper right arm.
2. Record review of the Resident #67’s (MONTH) 2019 POS showed an order, dated 4/19/19,
for [MEDICATION NAME] Solution Cartridge 100 units/ml (Insulin [MEDICATION NAME] – rapid
acting insulin); inject three units subcutaneously with meals related to diabetes.
Record review of the resident’s (MONTH) 2019 MAR indicated [REDACTED]
-[MEDICATION NAME] Solution Cartridge, 3 units, scheduled for 12:00 P.M. daily;
-Staff documented administration of the [MEDICATION NAME] Solution, 3 units, daily.
Observation and interview on 5/2/19, at 12:12 P.M., showed CMT B performed an AccuCheck
for the resident. The CMT said the resident had physician orders [REDACTED]. CMT B removed
the cap from the insulin pen, wiped the tip with an alcohol swab, and attached a
disposable needle. Without priming the pen, CMT B turned the dial on the pen to the 3
indicator mark and administered the insulin to the resident’s abdomen.
3. Record review Resident #4’s physician’s orders [REDACTED].>-an order for
[REDACTED].>-an order for [REDACTED].
Observation and interview on 5/2/19, at 8:01 A.M., showed CMT R had already performed an
AccuCheck for the resident. The CMT said resident had physician orders [REDACTED]. CMT R
removed the cap from the insulin pen, wiped the tip with an alcohol swab, and attached a
disposable needle. Without priming the pen, CMT R turned the dial on the pen to the 70
indicator mark and administered the insulin to the resident’s abdomen.
4. During an interview on 5/7/19, at 10:35 A.M., CMT L said he/she attended a specialized
class pertaining to insulin administration. At the conclusion of the class, he/she took
both a written and hands-on test to become certified to administer insulin in a nursing
facility. CMT L said he/she spent a day or two with CMT B as orientation at this facility
and received no instructions pertaining to priming insulin pens. CMT L was unaware of the
need to prime an insulin pen.
5. During an interview on 5/7/19, at 10:55 A.M., LPN M said an insulin pen should be
primed before the first use of the pen, but was not aware of recommendations to prime with
every use.
6. During an interview on 5/7/19, at 3:16 P.M., the Director of Nursing (DON) said insulin
pens should be primed with two units prior to every use.
MO 938, MO 966, MO 354, MO 428 and MO 587

F 0761

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

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.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation and interview, the facility failed to ensure stock medication was
stored in the original manufacturer’s packaging and failed to date a vial of insulin when
opened for one resident (Resident #70). The facility census was 142.
1. Observation and interview on 5/2/19, at 10:02 A.M., of the 300 hall medication cart
showed a clear plastic medication cup in the top drawer, which was filled with off-white
capsules. Handwritten on the outside of the cup in black marker was the word [MEDICATION

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265188

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

SPRING VALLEY HEALTH & REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

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 0761

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 53)
NAME]. Certified Medication Technician (CMT) A said staff had borrowed some of the
capsules from the stock bottle (used for administration to any resident with a physician
order [REDACTED]. During the observation, CMT A said, We probably shouldn’t do that.
2. According to the United States Food and Drug Administration, once opened insulin must
not be used after 28 days due to loss of potency and the risk of contamination.
According to the United States Pharmacopeia Dispensing Information (USPDI) as well as the
United States Food and Drug Administration (FDA), once opened, insulin must not be used
after 28 days due to loss of potency and the risk of contamination.
Record review of Resident #70’s admission Minimum Data Set (MDS – a federally mandated
assessment tool completed by facility staff), dated 3/14/19, showed the following:
-admitted to the facility on [DATE] from the hospital;
-Cognitively intact;
-Resident has [DIAGNOSES REDACTED].
Record review of the resident’s medication review report showed the following current
order:
-Humalog insulin (rapid action insulin) inject 10 units subcutaneously (SQ) with meals for
[DIAGNOSES REDACTED].
Record review of the resident’s electronic Medication Administration Record [REDACTED].
Observation and interview on 05/02/19, at 8:30 A.M., showed the following:
-Licensed Practical Nurse (LPN) MM stood outside of the resident’s room and prepared to
administer insulin to the resident;
-The nurse initially pulled a vial of [MEDICATION NAME] (long [MEDICATION NAME] insulin)
from the medication cart and then realized his/her mistake and replaced the [MEDICATION
NAME] into the cart and removed a vial of Humalog insulin from a box labeled with the
resident’s information on a prescription label;
-The nurse cleaned the top of the vial with an alcohol wipe and using an insulin syringe
to withdraw 10 units of Humalog insulin from the vial;
-The Humalog insulin vial did not have a date on the vial as to when staff opened the
vial;
-The nurse looked on the vial and on the box and said he/she could not find a date when
opened;
-The nurse entered the resident’s room cleaned the resident’s left upper arm with alcohol
and administered the insulin into the resident’s left upper arm.
During an interview on 5/06/19, at 3:55 P.M., the Registered Nurse/Unit Manager (RN) K
said the following:
-When a nurse opens a new vial of insulin that nurse is responsible for dating and
initialing the vial;
-The insulin is considered good for 28 days after opening, insulin dated older than 28
days should be discarded and replaced with a new vial;
-If an open vial of insulin is not dated when opened, that vial should be discarded and
replaced with a new vial of insulin.
During an interview on 5/07/19, at 3:15 P.M., the Director of Nursing (DON) said the
following:
-Nurses should date insulin when a new vial is opened;
-Insulin vials should be discarded 28 days after opening;
-Nurses should not administer insulin from an undated vial.

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265188

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

SPRING VALLEY HEALTH & REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

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 0761

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

F 0804

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Many

Ensure food and drink is palatable, attractive, and at a safe and appetizing
temperature.

Based on observation, interview, and record review, the facility failed to serve residents
palatable and attractive food. The facility census was 142.
Record review of the facility’s policy titled Meal Service-Menus and Recipes, dated
04/01/16, showed the following:
-Meals shall be prepared according to the facility approved menu;
-Corresponding recipes shall be used in conjunction with meal service.
Record review of the facility’s recipe titled Pureed Side Dishes-Noodles, dated (MONTH)
1997, showed the following;
-Place side dish in food processor, blend;
-If necessary, add small amount of broth or milk, and blend. Alternate adding broth or
milk and blending until consistency is smooth;
-Use only the amount of liquid necessary to puree the product. Do not increase or decrease
the amount of side dish.
Record review of the facility’s recipe titled Pureed Entrée (Meat, Poultry, Fish), dated
(MONTH) 1997, showed the following:
-Place entrée in blender, grind;
-Add bread, grind
-Add 4 ounces or half a cup of liquid, blend. Continue alternating adding a half a cup of
liquid until consistency is smooth and between pudding and mashed potato consistency.
1. Observation on 04/30/19, at 10:58 A.M., of the puree meal being prepared, showed the
following:
-Dietary Aide (DA) E place noodles in the food processor;
-DA E added two slices of bread, followed by water and thickener.
Observation on 04/30/19, at 1:30 P.M., showed the following:
-The regular lunch meal consisted of Swiss steak with tomatoes, buttered noodles, stewed
tomatoes, and bread with margarine;
-The puree lunch meal consisted of pureed Swiss steak, buttered noodles, and stewed
tomatoes;
-The Swiss steak had a dry texture and was hard to swallow;
-The noodles were bland, overcooked, and had a gummy texture;
-The pureed noodles were bland.
Observation on 05/01/19, at 1:35 P.M., showed the following:
-The regular lunch menu consisted of pork roast, mashed potatoes, and broccoli;
-The puree lunch menu consisted of pureed pork roast, broccoli, and mashed potatoes;
-The mashed potatoes were bland;
-The pureed broccoli was bland, and did not taste like broccoli.
Observation on 05/02/19, at 1:40 P.M., showed the following:
-The regular lunch menu consisted of baked chicken, mashed potatoes, and baby carrots;
-The baby carrots were mushy, with a mealy consistency.
Observation on 05/02/19, at 1:30 P.M., showed the following:
-The regular lunch menu consisted of breaded white fish, breaded popcorn shrimp, sugar
snap peas, and fruit gelatin with topping;
-The puree lunch menu consisted of pureed white fish with country gravy, mashed potatoes,
and fruit gelatin with topping;
-The breaded white fish was thin, approximately a fourth of an inch thick, rectangles;

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265188

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

SPRING VALLEY HEALTH & REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

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 0804

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Many

(continued… from page 55)
-The puree white fish was mechanical consistency, as it had small chucks;
-The snap peas had a slick texture and had a mushy consistency.
During an interview on 04/25/19, at 10:53 A.M., Resident #57 said the food is bland and
often it consists of only starchy foods.
During an interview on 04/30/19, at 10:58 A.M., DA E said he/she follows the puree
recipes. He/she always adds thickener to the purees.
During an interview on 05/07/19, at 1:49 P.M., the Dietary Manager (DM) said staff are to
follow the recipe when preparing puree meals. Staff can add thickeners if there is an
inconsistency issue, however they should not add it if not necessary. Puree meals should
have a smooth consistency. The DM said she tastes the food prior to it being served to
ensure quality.
During an interview on 05/07/19, at 3:19 P.M., the Administrator said the food should look
appetizing and taste good.
MO 938 and MO 354

F 0806

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Ensure each resident receives and the facility provides food that accommodates resident
allergies, intolerances, and preferences, as well as appealing options.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview, and record review, the facility failed to determine and
honor one resident’s (Resident #236) religious food preferences. A sample of 32 residents
was selected for review in a facility with a census of 142.
Record review of the facility’s policy titled, Meal Service-Alternates and Substitutes,
dated 4/01/16, showed the following information:
-Purpose to ensure residents receive adequate nutrition and hydration and to ensure
resident preferences are honored and monitored;
-Alternates shall be available for all meals for residents who dislike the menu item;
-Alternates whether on a selective menu or always available menu must be approved by a
consultant registered dietitian (RD);
-Alternates shall be offered to residents who refuse the menu items. In cases where the
menu item as well as the alternate is refused, staff shall investigate a reasonable
solution within product availability;
-When resident choices interfere with appropriate nutritional practices, information shall
be documented in the resident care plan;
-Alternates shall be prepared and made available at all meals;
-Residents who refuse the menu item based on preference, shall be offered a reasonable
alternative within product availability and consistent with nutritional value;
-The dietary manager (DM) shall monitor meal service to ensure alternate are available.
1. Record review of Resident #236’s admission record (face sheet) showed the following:
-admitted to the facility on [DATE] from the hospital;
-Religion unknown.
Record review of the resident’s medication review report, dated (MONTH) 2019, showed an
physician orders, dated 4/11/19, for regular diet, mechanical soft texture.
Record review of the resident’s care plan, dated 4/11/19, showed the following:
-Resident has an activities of daily living (ADL- dressing, grooming, bathing, eating, and
toileting) self-care performance deficit related to [MEDICAL CONDITION] (paralysis of one

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265188

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

SPRING VALLEY HEALTH & REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

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 0806

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 56)
side of the body) and stroke diagnoses;
-Resident requires extensive assistant by one staff to eat, aspiration risk;
-Resident has a communication problem related to [MEDICAL CONDITION] (an impairment of
language, affecting the production or comprehension of speech and the ability to read or
write);
-Staff to anticipate and meet needs;
-Resident is able to nod head yes or no;
-The care plan did not address a meal preference for the resident.
Record review of the resident’s admission nurse note dated 4/12/19, at 9:11 A.M., showed
the following:
-Late entry for 4/11/19 at 11:40 P.M.;
-Resident arrived from the hospital;
-admission orders [REDACTED]
-Resident is non-verbal, but is able to follow conversation and make needs known by
nodding or shaking head.
Record review of the resident’s activity progress note dated 4/12/19, at 12:22 P.M.,
showed the activity assistant documented the following:
-Resident only able to answer yes and no to the questions asked;
-Resident enjoys music, being outside, puzzles, reading, religion, television, due to
his/her inability to speak, it is unknown what exact things the resident is into.
Record review of the resident’s admission minimum data set (MDS – a federally mandated
assessment tool completed by facility staff), dated 4/18/19, showed the following:
-Severe cognitive impairment;
-Disorganized thinking, behavior present, fluctuates (comes and goes);
-Very important to the resident to participate in religious practices;
-[DIAGNOSES REDACTED].
-Resident has feeding tube and consumes mechanically altered diet for nutritional needs;
-Receives physical therapy (PT), occupational therapy (OT), and speech therapy (ST), five
times per week each.
Record review of the resident’s social service admission note dated 4/18/19, at 3:49 P.M.,
showed the following:
-Severe cognitive impairment;
-No depression;
-Resident is his/her own responsible party;
-Resident expressed that his/her discharge plan is to go back home with family;
-The note did not address any religious preference of the resident.
Record review of the resident’s nutritional assessment, dated 4/18/19, completed by the
dietitian, showed the following:
-Mechanical soft diet;
-Glucerna (a high calorie nutritional formula) 1.5 calorie at 60 ml/hour (hr) until 1200
milliliters (ml) infused with 60 ml/hr autoflush;
-No known food allergy;
-Monitor intake;
-The assessment did not address any religious preferences.
Record review of the resident’s social services evaluation, dated 4/18/19, showed the
following:
-Religious/cultural/hobbies section left blank;
-Staff failed to answer questions about the resident’s religious affiliation/church,
cultural/spiritual influences, medical sanctions or restrictions, or what faith traditions
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265188

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

SPRING VALLEY HEALTH & REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

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 0806

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 57)
are important to the resident.
Record review of the resident’s care plan, revised on 4/25/19, showed the resident’s
religion is non-denominational.
Observation on 4/30/19, at 1:20 P.M., showed the following:
-The resident had a meal of a slice of plain bread an unopened tub of butter, buttered
pasta with no sauce, and ground meat with stewed chunks on the meat, the resident had a
glass of lemonade to drink;
-The resident did not eat the ground meat.
Observation and interview on 5/01/19, at 1:15 P.M., showed the following:
-The resident lay in bed with a lunch tray on the over bed table across the resident’s
bed;
-The resident ate stuffing covered with gravy and a dry roll, the resident pointed to the
meat and asked what it was. When told the meat was pork roast, the resident shoved the
entire over table away from the bed and frowned;
-The resident indicated he/she did not like pork because of religious reasons;
-The resident indicated no staff had asked the resident about his/her food preferences.
During an interview on 5/02/19, at 10:45 A.M., Registered Nurse/Unit Manager (RN) K said
he/she did not know if the dietitian ever saw the resident.
During an interview on 5/02/19, at 11:24 A.M., the Director of Nursing (DON) said if a
resident needs a new diet ordered, the DON or a nurse would contact the physician.
During an interview on 5/02/19, at 12:30 P.M., the Dietary Manager (DM) said the
following:
-The facility previously had a full time RD, who left in (MONTH) 2019;
-Since the beginning of the year, the dietitian charts remotely on the residents;
-The DM said she has seen the RD one time in the facility;
-The DM said she attempted to talk with the resident about his/her food preferences, but
the resident has a communication problem;
-The DM was unaware of any special dietary needs/religious preferences/restrictions;
-The DM said he/she has not attempted to contact the resident’s family to discuss the
resident’s preferences.
During an interview on 5/02/19, at 2:00 P.M., a family member of the resident said the
following:
-Another family member tried to talk with different facility staff about not giving the
resident pork, but the resident is still being served pork;
-The family member said the resident does not eat pork for religious reasons.
During an interview on 5/07/19, at 8:20 A.M., Speech Therapist (ST) JJ, said the resident
refused to eat bacon in the past, but the ST was unsure of the reason.
During an interview on 5/07/19, at 8:35 A.M., the Social Service Coordinator (SSC) said
the SSC has not spoken with the resident’s family and was unaware of any religious/food
preferences.
During an interview on 5/07/19, at 9:32 A.M., the Activity Director (AD) said the
following:
-On the resident’s initial activity assessment completed by the activity assistant, the
resident indicated that his/he religious preference was non-denominational;
-Today, the resident is indicating he/she is kosher, so the AD will notify dietary.
During an interview on 5/07/19, at 11:05 P.M., the DON said the DON said the admissions
coordinator and the activity department are responsible for determining resident food
preferences and religious restrictions.
During an interview on 5/07/19, at 1:15 P.M., the admissions nurse said the following:
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265188

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

SPRING VALLEY HEALTH & REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

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 0806

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 58)
-He/she visited with the resident on admission, but the resident was non-verbal, so he/she
had no way of finding out the resident’s religious preferences;
-He/she documented unknown on the resident’s religion;
-He/ she never got an opportunity to contact the resident’s family.

F 0812

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Many

Procure food from sources approved or considered satisfactory and store, prepare,
distribute and serve food in accordance with professional standards.

Based on observation, interview, and record review, the facility failed to serve food
under sanitary conditions when the facility staff stacked dishes wet, failed to perform
proper hand hygiene, failed to wear a proper hair restraint; and failed to keep a resident
use refrigerator clean. The facility had a census of 142 residents.
1. Record review of the 2013 Missouri Food Code showed the following information:
-After cleaning and sanitizing, equipment and utensils shall be air-dried;
-May not be cloth dried.
Observation of the kitchen on 05/01/19, at 1:40 P.M., showed eight warming lids stacked
wet.
Observation of the kitchen on 05/03/19, at 1:30 P.M., showed nine warming lids stacked
wet.
Observation of the kitchen on 05/07/19, at 11:00 A.M., showed the following:
-Four small steam pans stacked wet;
-Two large steam pans stacked wet;
-Six dinner plates stacked wet;
-Thrity-three fruit cups in a large bin stacked wet;
-Dietary Aide (DA) G stacking visibly wet trays out of the dishwasher.
During an interview on 05/07/19, at 1:51 P.M., the Dietray Manager (DM) said when staff
are putting dishes away, they should ensure the dishes are clean and dry.
During an interview on 05/07/19, at 2:03 P.M., DA G said prior to putting dishes away,
he/she makes sure his/her hands are clean hands and the dishes are clean and dry.
During an interview on 05/07/19, at 11:35 A.M., DA F said dishes need to be clean and
pretty well dry before putting away.
2. Record review of the facility’s policy titled, Sanitation-Handwashing, dated 04/01/16,
showed the following:
-Employees shall wash their hands after handling soiled equipment, as much as possible
during food preparation to remove soil and contamination and to prevent cross
contamination, when changing tasks, before donning gloves, and after engaging in any
activity or task which contaminates hands.
Record review of the 2013 Missouri Food Code showed the following information:
-Food employees shall clean their hands and exposed portions of their arms immediately
before engaging in food preparation including working with exposed food, clean equipment
and utensils, and unwrapped single-service and single-use articles;
-After engaging in other activities that contaminate the hands.
Observation of the kitchen on 04/30/19, begining at 11:00 A.M., showed the following:
-DA E wearing gloves while serving out food and cooking grilled sandwiches. DA E touched
the sandwich with gloved hands and then removed gloves;

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265188

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

SPRING VALLEY HEALTH & REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

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

(continued… from page 59)
-DA E left the kitchen and returned. The DA did not perform hand hygiene and reapplied
gloves;
-DA F put on gloves, no hand hygiene observed;
-DA F touched bread and cheese with gloved hands and placed sandwiches in a bin;
-DA F went into dry storage with gloved hands to get a new loaf of bread, removed twist
tie, and continued making sandwiches;
-DA F placed the bin of sandwiches in the walk-in refrigerator while still wearing gloves;
-DA F then directly touched cheese and wrapped in saran wrap with the same gloved hands;
-DA E put on gloves without performing hand hygiene. He/she started to puree vegetables;
-DA E directly touched bread with gloved hands;
-DA E took off his/her gloves and touched the trashcan lid with bare hands. The DA did not
perform hand hygiene;
-DA E wrapped a steam tray with saran wrap and then retrieved clean serving utensils;
-DA F put on a pair of gloves without performing hand hygiene. DA F removed sandwiches
from the fridge, moved carts, rearranging bins, took off glasses and put back on, and then
got ice. DA F removed gloves and put on a new pair without performing hand hygiene. He/she
then touched bread.
-DA F removed pudding from walk-in refrigerator with gloved hands. He/she then placed
bread on resident’s plates, while also touching individual butter cups, hall tray carts,
and the sandwich bin;
-DA F went in walk-in refrigerator to a get salad. He/she did not removed their gloves and
continued placing bread on resident’s plates;
-DA E served food onto resident’s plates with gloved hands. He/she touched lids, utensils
other staff had touch, and directly touched noodles on a resident’s plate;
-DA F closed up hall cart with his/her gloved hands. He/she pushed the cart out of the way
and pulled over a new cart. He/she then put a new pair of gloves over her existing pair.
He/she continued to place bread on resident’s plates.
-DA F entered the walk-in refrigerator with gloved hands, got fruit plate, and then
directly touched a grilled cheese sandwich;
-DM put on gloves without performing hand hygiene. The DM pushed drink cart, got a pair of
scissors, went into dry storage, directly touched hot dog buns, and then proceeded to roll
silverware in napkins;
-DA F went into the walk-in refrigerator with gloved hands and retrieved hot dogs;
-DA E while wearing gloves, took the hot dogs over to prep area and wrapped in saran wrap.
He/she removed gloves, put the hot dogs in walk-in refrigerator. He/she put on new gloves
wihtout performing hand hygiene;
-DA F still wearing the same gloves, cut up hot dog buns, then pulled up room tray cart.
He/she then touched bread and a grilled cheese sandwich.
Observation of the kitchen on 05/01/19, at 1:35 P.M., showed DA F wearing gloves. He/she
placed rolls on resident’s plates with his/her gloved hands. He/she then touch a hall tray
cart and then placed a second pair of gloves over his/her existing gloves.
During an interview on 05/07/19, at 11:26 A.M., DA E said he/she will wash hands before
serve out and will do again when changing tasks. He/she will wash hands between each use
if wearing gloves.
During an interview on 05/07/19, at 1:51 P.M., the DM said staff are to wear gloves when
handling ready to eat food. Staff must change gloves and wash hands when changing tasks.
Staff need to wash their hands when they enter the kitchen and before putting on gloves.
Staff should not put on two pairs of gloves.
During an interview on 05/07/19, at 11:35 A.M., DA F said he/she washes hands and puts on
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265188

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

SPRING VALLEY HEALTH & REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

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

(continued… from page 60)
a fresh pair gloves frequently. He/she will put on gloves over top of old gloves. Everyone
working in the kitchen needs hair net.
3. Record review of the 2013 Missouri Food Code showed the following information:
-Food employees shall wear hair restraints such as hats, hair coverings or nets, beard
restraints, and clothing that covers body hair, that are designed and worn to effectively
keep their hair from contacting exposed food; clean equipment, utensils, and linens; and
unwrapped single-service and single-use articles.
Observation of the kitchen on 04/30/19, starting at 11:00 A.M., showed DA G in the kitchen
without a hair net.
Observation of the kitchen on 05/01/19, at 1:40 P.M., showed DA G in the kitchen without a
hair net.
Observation of the kitchen on 05/03/19, at 1:30 P.M., showed DA G in the kitchen without a
hair net.
Observation of the kitchen on 05/07/19, at 11:00 A.M., showed DA G in the kitchen without
a hair net.
During an interview on 05/07/19, at 11:26 A.M., DA E said anyone working in the kitchen
must have a hair net.
During an interview on 05/07/19, at 1:51 P.M., the DM said staff must wear hair nets.
During an interview on 05/07/19, at 11:35 A.M., DA F said everyone working in the kitchen
needs hair net.
4. Observation on 05/07/19, at 11:30 A.M., showed the following:
-A food refrigerator used for resident foods had multiple dried sticky fluid spills on the
shelving and on the floor of the refrigerator which were brown and yellow in color.
During an interview on 5/07/19, at 11:45 A.M., Licensed Practical Nurse (LPN) M said the
night shift nursing staff are responsible for cleaning resident food refrigerator.
During an interview on 5/07/19, at 11:50 A.M., the Director of Nursing (DON) said the
following:
-Nursing staff (no specific staff member designated) is responsible for cleaning the
resident food refrigerators in the medication room;
-The DON said she did not have a cleaning schedule for the refrigerator.

F 0880

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Provide and implement an infection prevention and control program.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation and interview, the facility failed to ensure staff followed
acceptable standards of practice for infection control when they did not properly clean
and disinfect glucometers (digital machine used to test the glucose/sugar level in blood)
for two randomly observed residents (Residents #20 and #89). The facility census was 142.
Record review showed the facility did not provide a policy pertaining to glucometer use
and cleaning.
According to the manufacturer’s label for Micro-Kill Plus Disinfectant Wipes, the product
is effective [MEDICAL CONDITION] ([MEDICAL CONDITION]-resistant staphylococcus aureus),
VRE ([MEDICATION NAME]-resistant [MEDICATION NAME]), and other [MEDICAL CONDITION] in two
minutes. The surface being cleaned should remain wet throughout that timeframe.
1. During an observation on 5/1/19, at 11:10 A.M., Certified Medication Tech (CMT) R
performed an AccuCheck (blood test to determine sugar level) for Resident #20 in the

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265188

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

SPRING VALLEY HEALTH & REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

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 0880

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 61)
resident’s room. CMT R returned to the medication cart and placed the glucometer on top of
the cart. CMT R retrieved an alcohol swab from the cart, wiped off the machine for less
than 10 seconds, and then placed the glucometer directly back into a box inside the right
bottom draw in the contaminated medication cart.
2. During an observation and interview on 5/2/19, at 8:12 A.M., showed CMT A performed an
AccuCheck for Resident #89 in the resident’s room. CMT A returned to the medication cart
and placed the glucometer on top of the cart. The CMT said he/she didn’t know what other
staff did, but he/she thought the machine should be cleaned between uses. CMT A retrieved
a Microkill disinfectant wipe, wiped off the machine for less than 10 seconds, and then
placed the glucometer directly back on the top of the contaminated medication cart.
3. During an interview on 5/7/19, at 10:35 A.M., CMT L said he/she used an alcohol swab to
wipe off the glucometer before and after use. He/she said another CMT spent a day or two
oriented him/her upon hire.
4. During an interview on 5/7/9, at 3:16 P.M, with the Administrator and the Director of
Nursing (DON), the DON said staff should use a Microkill wipe to clean off a glucometer
after use. The machine should then be placed on a barrier cloth to air dry for at least
two minutes.
MO 428

F 0921

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

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

Based on observation and interview, the facility failed to maintain a clean medication
room floor located in the 500-600 hall medication room. The facility census was 142.
1. Observation on 05/07/19, at 11:30 A.M., of the 500-600 hall medication room showed a
brown dried substance smeared over approximately a three foot area on floor.
During an interview on 5/07/19, at 11:35 A.M., Certified Medication Technician (CMT) GG
said he/she was unsure of what the dried brown substance on the floor was.
During an interview on 5/07/19, at 11:45 A.M., Licensed Practical Nurse (LPN) M said
housekeeping is responsible for cleaning the floor of the medication room.
During an interview on 5/07/19, at 11:50 A.M., the Director of Nursing (DON) said
housekeeping is responsible for cleaning the medication room floors.
MO 834, MO 938, MO 975 and MO 486