Spring Valley Health & Rehab: Catheter Care Failures - MO
The finding came through three separate complaints filed against the facility. Inspectors reviewed catheter care records and interviewed nearly every level of the nursing hierarchy, from floor staff to the administrator. Every person they spoke with said the same thing: document it, check the urine, tell the doctor. Nobody had.
The resident's situation was already complicated. A nurse practitioner told inspectors the resident had consulted with urology during a prior hospital stay and had blood present in the catheter bag, though she noted the blood was not frank red. The urologist, she said, was aware and had requested no changes. The resident had also asked to have the catheter removed.
What the nurse practitioner described to inspectors was a patient whose condition was being actively monitored by a specialist. What the inspection found was a care team that wasn't keeping up its end of that monitoring on paper, and wasn't looping in the facility's own medical director.
The medical director told inspectors he expected staff to inform him if a resident had any blood in their catheter bag, and that any such notification should be documented in the resident's medical record. He said catheters should be replaced once a month, catheter care should be provided and recorded every shift, and urine output should be tracked. When inspectors asked whether staff had done those things, the record showed they had not documented the blood or the notification.
LPN B and Registered Nurse X both told inspectors, in separate interviews, that monitoring urine color, amount, and odor was a basic part of caring for a resident with a catheter. Both said staff should notify the physician when something was wrong and record catheter care on the Treatment Administration Record every shift. The Director of Nursing said staff should document red or dark urine. The administrator said she expected documentation of urine output and catheter care for any resident with a catheter.
The gap between what everyone said should happen and what the records showed had happened was the violation.
Catheter-associated infections are among the most common and preventable complications in long-term care. Blood in a catheter bag can signal infection, trauma, or other underlying problems. Whether the blood in this resident's case required intervention or not, the facility's own medical director said he needed to know about it, and the record showed he wasn't told.
The deficiency was cited at a level of minimal harm or potential for actual harm, affecting a small number of residents. It is the least severe category on the federal scale, but the underlying failure, a care team that unanimously described proper protocol and then didn't follow it, runs through every interview in the inspection report.
The resident, meanwhile, had asked to have the catheter taken out.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Spring Valley Health & Rehabilitation Center from 2025-08-25 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: July 2, 2026 · Our methodology
SPRING VALLEY HEALTH & REHABILITATION CENTER in SPRINGFIELD, MO was cited for violations during a health inspection on August 25, 2025.
The finding came through three separate complaints filed against the facility.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.