Spring Valley Health & Rehab: Insulin Errors Found - MO
Her managers said she was wrong.
The inspection, completed August 25, 2025, stemmed from two separate complaints. What investigators found was a medication error unfolding in plain view, at 12:24 in the afternoon, with a resident whose blood sugar had just been checked at 148 mg/dL.
RN O drew up nine units of Humalog, administered the insulin, and never primed the pen. When inspectors asked about it afterward, she explained her reasoning in full. Staff don't prime insulin pens, she said. The pens have plungers, so there's no need. If bubbles appear, the nurse just has to watch how she positions the pen. And if a little air does get injected, it won't hurt the resident.
None of that was accurate, according to every supervisor interviewed.
The Director of Nursing said insulin pens are required to be primed before each use, every pen, every time, and that this is the manufacturer's guidance. She said a dose would not be correctly administered if the pen wasn't primed first. The administrator confirmed the same. A corporate nurse consultant, brought in separately, said staff should always prime insulin pens with each use.
RN C, interviewed two days after the observed injection, said she wasn't aware that priming was required each time. She thought it only applied to new pens.
So two nurses, working in the same facility, administering insulin to residents with conditions serious enough to require daily blood sugar monitoring and scheduled injections, did not know a basic step in the process. One of them had developed an explanation for why the step wasn't necessary.
Priming an insulin pen removes air from the needle and confirms the pen is working and delivering medication. Skipping it means the first portion of a dose may be air rather than insulin, and the resident receives less medication than prescribed. For a diabetic patient, a consistently under-delivered insulin dose can mean blood sugar that doesn't come down the way it should, over hours or days, without anyone understanding why.
The deficiency was cited at the level of minimal harm or potential for actual harm, and listed as affecting some residents, meaning more than one person was potentially exposed.
What the inspection record doesn't resolve is how long this had been happening. RN O didn't describe skipping the step as a one-time mistake or an oversight. She described it as policy. Staff don't prime insulin pens, she said, as if that were simply how things were done there. RN C's confusion about new pens versus pens in active use suggests the misunderstanding wasn't isolated to a single nurse or a single shift.
The facility's own leadership knew the correct procedure. The Director of Nursing, the administrator, and the corporate consultant all gave the same answer within minutes of being asked. The knowledge existed. It hadn't reached the nurses giving the injections.
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.
Her managers said she was wrong.
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.