Spring Valley Rehab: Feeding Tube Care Failures - MO
It wasn't the only recording problem. On a separate occasion, staff documented that the resident received fewer milliliters than the ordered amount as well. Federal inspectors cited the facility following a complaint investigation completed November 21, 2025.
The facility's registered dietician, who reviews tube feeding orders and monitors whether changes are needed, told inspectors she was not sure what intake amounts staff should be documenting. That uncertainty is notable: tube feeding is not an incidental task. For residents who cannot eat on their own, the formula delivered through a feeding tube is their entire nutritional and caloric intake. Getting the recorded amount wrong by more than 1,300 milliliters in a single day is not a rounding error.
Inspectors also found that when a tube feeding is not given for any reason, staff were expected to document why in the resident's medication administration record. There was no indication that was happening consistently.
The citation was classified as causing minimal harm or potential for actual harm, and inspectors noted that only a few residents were affected. CMS assigned it an F0693 deficiency tag.
What the records cannot answer is whether the documentation errors reflected what staff actually delivered, or whether the numbers on paper simply never matched what went into the line. The dietician who reviews those records said she didn't know what the correct figures should be. Nobody, it appears, had told her.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Spring Valley Health & Rehabilitation Center from 2025-11-21 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: August 5, 2026 · Our methodology
SPRING VALLEY HEALTH & REHABILITATION CENTER in SPRINGFIELD, MO was cited for violations during a health inspection on November 21, 2025.
It wasn't the only recording problem.
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.