Spring Valley Health & Rehab: Missed Meals Before Dialysis - MO
The resident's meal tray had been prepared. Dietary staff pulled a census sheet that morning, printed tickets, and checked each name to make sure every resident was accounted for. The tray was on the dining room cart. It just never made it to the resident's room.
A dietary staff member told inspectors during the August 25 visit that she did not know why no one had brought it.
The resident was among a group of patients whose eating schedules are built around dialysis appointments. Some want to eat before they leave. Some want a sack lunch to take with them, typically a deli meat or peanut butter sandwich, fresh fruit, chips, and applesauce or pudding. Some want their meal reheated when they return. The facility said it had a system for all of this. That Thursday, the system did not work.
The Director of Nursing learned about the missed meal during an interview with inspectors at 11:20 that morning. She said residents going to dialysis should be offered breakfast, that nursing staff should notify the kitchen and arrange a sack meal if needed, and that a nutrition assessment should be on file documenting each resident's preferences. She had not known the resident missed breakfast.
Forty minutes later, the Administrator offered a slightly different account of how the process was supposed to work. Residents, she said, need to speak with the Dietary Manager directly to arrange a pre-dialysis meal. Staff should be asking about meal timing preferences at the time of admission. At minimum, she said, the resident should have received something in a paper sack before leaving. That had not happened either.
The deficiency was cited under the federal tag covering nutrition and hydration, with inspectors noting minimal harm or potential for actual harm affecting a small number of residents.
The violation is not the most dramatic finding a nursing home can receive. No one was hospitalized. The harm level was listed at the lower end of the scale. But dialysis is physically demanding, and patients are routinely advised to eat before sessions to help stabilize blood sugar and maintain energy through treatment. Going without a meal before dialysis is not a trivial inconvenience for someone already managing kidney failure.
What the inspection captured, in a narrow way, is the distance between a facility's stated procedures and what actually happens to a specific person on a specific Thursday morning. The tray was prepared. The names were checked. The system, on paper, was running. The resident left for dialysis without eating, and the tray sat on the cart until someone noticed it was still there.
The Director of Nursing and the Administrator each described what should have occurred. Neither had known it didn't.
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's meal tray had been prepared.
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.