Spring Valley Health: Wound Care Delays for Stage 3 Ulcer - MO
The wound care orders weren't entered until June 13, 2025, three days after the resident was admitted on June 10. Whether any treatment happened in those three days, the inspection record doesn't show, because staff didn't document it.
A Stage 3 pressure ulcer is a deep wound. Tissue has broken down through the full thickness of skin into the layer beneath. The Medical Director, interviewed by inspectors on August 25, said he considered a Stage 3 "significant." He said he expected staff to notify him immediately if a resident arrived with a wound that serious and no treatment orders in place. He said staff should have called him before the wound doctor ever set foot in the building.
Nobody called.
The Admissions Director told inspectors the wound orders were entered on June 10, the day of admission, and that treatment should have started that day or the following day at the latest. The Director of Nursing agreed: staff should have called the physician to confirm orders and started wound treatments the next morning. The Administrator said staff have 24 hours to complete a full assessment, that the wound nurse should observe any resident with a wound on or immediately after admission, and that she expected wound treatments to be documented on the Treatment Administration Record.
The nurse practitioner, interviewed on August 22, said she didn't know for certain why wound orders weren't entered until June 13. She said if the resident came from a hospital, staff would typically use the discharge orders. She said if no orders existed, staff should have notified the physician right away. She said she expected documentation of every treatment, and that if a resident refused care, staff were supposed to notify the provider and write it in the progress notes.
There is no indication in the inspection record that anyone notified anyone.
Five separate complaints were filed with regulators about conditions at Spring Valley, all tied to this inspection. The survey was completed August 25, 2025.
What emerges from the interviews isn't a dispute about what should have happened. Every manager, every clinician, every coordinator said the same thing: call the physician, start treatment within a day, document everything. The Admissions Director said it. The DON said it. The Administrator said it. The Medical Director said it. The nurse practitioner said it.
What none of them could fully explain was why none of it happened.
The MDS Coordinator, interviewed August 22, said simply that she expected staff to document wound treatments. The inspection record does not indicate that they did.
A Stage 3 pressure ulcer, left untreated, does not stay a Stage 3. The tissue continues to break down. Infection becomes a serious risk. The longer the wound goes without proper cleaning, dressing, and monitoring, the harder it becomes to heal, and the more dangerous it becomes for the person living inside that skin.
The resident's name does not appear in the inspection record. What does appear is a timeline: admitted June 10, orders entered June 13, treatments undocumented, and a string of managers who all knew exactly what should have been done and could not account for why it wasn'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 wound care orders weren't entered until June 13, 2025, three days after the resident was admitted on June 10.
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.