Spring Valley Health & Rehab: Medication Gaps - MO
The resident had been prescribed metoprolol extended-release, a drug used to treat high blood pressure, chest pain, and heart failure. The order, dated August 7, carried a specific instruction: hold the medication if the resident's systolic blood pressure dropped to 100 millimeters of mercury or below, and notify a physician if it was held three doses in a row. On August 7, staff documented the medication was given, with a blood pressure reading of 143/64. Then the record goes blank. August 8, 9, 10, and 11 show nothing, no indication the drug was administered, no indication it was withheld, no explanation of any kind.
The same four-day gap appeared for ferrous sulfate, an iron supplement the resident was taking for anemia. Documented on August 7. Silent after that.
Federal inspectors cited Spring Valley under F0755, the standard governing medication administration, following a complaint inspection completed August 25, 2025. Four separate complaints had been filed: numbers 1534273, 1534275, 2572207, and 2585250.
What made the inspection notable was not just what the records showed, but how uniformly the staff described what the records were supposed to show. Every person interviewed said the same thing.
Certified Medication Technician AA, interviewed at 9:15 in the morning on August 25, said staff should document on the medication administration record any administered medications. CMT D, interviewed three days earlier, said staff should be documenting medications as administered or not administered, with a reason, and that there should not be blank areas on the MAR. CMT A said the same thing, nearly word for word, at 12:30 that afternoon. RN C said it ten minutes later.
The Director of Nursing said it too. "If it was not documented, it was not done."
The Administrator, interviewed at 12:29 p.m. on August 25, said she expected staff to administer residents' medications as ordered and document on the MAR. Staff should be documenting medication as administered or not administered, with the reason. There should not be blank areas.
Six people, from bedside medication technicians up through the administrator, described a standard that the facility's own records showed had not been followed. None of them disputed what the MAR showed. None offered an explanation for the gap.
The metoprolol order included a built-in warning system: if the drug was held three consecutive times, someone was supposed to call the physician. That safeguard only works if someone records whether the drug was given. Four blank days meant there was no way to know whether the threshold had been reached, no way to know whether a physician should have been called, and no way to know whether the resident's blood pressure had dropped into the range where holding the drug was required in the first place.
CMS rated the violation at a level of minimal harm or potential for actual harm, and noted that some residents were affected.
Whether the medications were given during those four days, nobody said. The records don't show it. And as the Director of Nursing put it, if it wasn't documented, it wasn't done.
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 resident had been prescribed metoprolol extended-release, a drug used to treat high blood pressure, chest pain, and heart failure.
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.