
Report
TheVardellReport
Spring Valley Health & Rehabilitation Center
Skilled nursing facility and nursing facility
2915 South Fremont Ave
Springfield, MO 65804

TheVardellReport
Skilled nursing facility and nursing facility
2915 South Fremont Ave
Springfield, MO 65804
Life by Vardell Presents
The deeper story, beautifully organized. Available records, historical context, and questions worth asking.
This report is free. Vardell does not certify, grade or endorse; it shows what the record documents.
The Essentials
Across 13 inspections from May 2021 to May 2026, state surveyors documented 68 findings at Spring Valley Health & Rehabilitation Center; 68 have a recorded correction; CMS lists 1 enforcement action in the window.
* Partial year, through October 1, 2026.
| Year | Inspections | Findings | Of which, actual harm (level G or above) |
|---|---|---|---|
| 2021 | 1 | 13 | 2 |
| 2022 | 0 | 0 | 0 |
| 2023 | 2 | 19 | 0 |
| 2024 | 3 | 8 | 0 |
| 2025 | 5 | 25 | 0 |
| 2026 | 2 | 3 | 0 |
Chronology
Every inspection in the record window, newest first. A finding is a deficiency an inspector cited. CMS publishes what a complaint investigation cited, not what the complaint alleged.
2 findings
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
1 finding
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
2 findings
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
19 findings
The same visit included a complaint investigation.
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
1 finding
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
1 finding
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
2 findings
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
5 findings
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
1 finding
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
2 findings
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
17 findings
Enforcement Action
Denial of payment imposed December 13, 2024. Status: Closed, March 15, 2025. CMS does not tie a penalty to a survey; listed with the standard health inspection of December 21, 2023, the nearest before the penalty date.
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
2 findings
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
13 findings
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Severity levels follow the CMS scope and severity grid. A–C: potential for minimal harm. D–F: no actual harm, potential for more than minimal harm. G–I: actual harm. J–L: immediate jeopardy.
Context
A repeated citation can merit attention, but context and corrective action must be reviewed before drawing a conclusion.
Inspectors cited F684 in May 2021, December 2024, November 2025, February 2026 and May 2026. This citation covers whether residents receive the treatment their orders, preferences and goals call for. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
Inspectors cited F584 in December 2023, April 2024 and August 2025. This citation covers whether rooms and shared spaces are kept safe, clean, comfortable and homelike. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
Inspectors cited F609 in May 2021, January 2024 and January 2025. This citation covers whether suspected abuse, neglect or theft is reported to the authorities on time, with the results of the home’s investigation. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
Inspectors cited F610 in May 2021, January 2024 and January 2025. This citation covers how the home responds to and investigates an allegation of abuse, neglect or mistreatment. The most serious of these was recorded at level J (immediate jeopardy). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
Inspectors cited F686 in May 2021, December 2024 and August 2025. This citation covers how the home prevents and treats pressure injuries (bedsores). None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
Inspectors cited F761 in May 2021, December 2023 and December 2024. This citation covers how drugs are labeled and kept locked, including controlled drugs. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
Inspectors cited F812 in May 2021, December 2023 and August 2025. This citation covers how food is stored, prepared and served. None rose above level F (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
Inspectors cited F842 in December 2023, December 2023 and August 2025. This citation covers whether resident records are complete, accurate and kept confidential. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
Inspectors cited F880 in December 2023, December 2024 and May 2026. This citation covers hand hygiene, isolation practice and the home’s infection-prevention program. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
Inspectors cited F658 in May 2021 and February 2025. This citation covers whether the home’s services meet professional standards of quality. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
Inspectors cited F690 in March 2025 and August 2025. This citation covers continence care, catheter care and preventing urinary tract infections. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
Inspectors cited F692 in December 2023 and August 2025. This citation covers whether residents get enough food and fluids to stay healthy. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
Inspectors cited F693 in December 2023 and November 2025. The agency describes it this way: Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
Inspectors cited F698 in December 2023 and August 2025. This citation covers care for residents who need dialysis. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
Inspectors cited F759 in December 2023 and August 2025. This citation covers whether medication errors stayed under 5 percent when inspectors watched medications being given. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
Inspectors cited F760 in December 2024 and August 2025. This citation covers whether residents are free from significant medication errors. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
Inspectors cited F921 in May 2021 and August 2025. The agency describes it this way: Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. None rose above level F (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
For Your Next Visit
Bring these to the tour. Each one comes from something in the record; the reason is under the question.
How do nurses make sure a doctor’s orders are carried out, and how are families told when something is missed?
Quality of Care: cited in five inspections, most seriously at level E.
What was done about the cleanliness citation, and how are rooms and shared spaces checked now?
A Clean, Homelike Setting: cited in three inspections, most seriously at level E.
How are staff trained to report suspected abuse or neglect, and who reports it to the state?
Reporting Suspected Abuse: cited in three inspections, most seriously at level D.
When an allegation is made, who investigates it, and how are residents protected in the meantime?
Investigating Alleged Violations: cited in three inspections, most seriously at level J.
How often are residents checked for pressure injuries and repositioned, and who is responsible for it?
Pressure Injury Care: cited in three inspections, most seriously at level E.
How are medications stored and secured, and who checks the medication carts?
Medication Labeling and Storage: cited in three inspections, most seriously at level E.
May we see the kitchen, and what do your own sanitation checks look like week to week?
Kitchen and Food Safety: cited in three inspections, most seriously at level F.
How can a family request a resident’s records, and how are they kept accurate?
Medical Records: cited in three inspections, most seriously at level E.
Who leads infection control here, and how often are hand-hygiene and isolation practices audited?
Infection Control: cited in three inspections, most seriously at level E.
How do you check that nurses and aides follow professional standards, and what happens when they do not?
Professional Standards: cited in two inspections, most seriously at level D.
How is continence care scheduled, and how do you prevent urinary infections?
Continence and Catheter Care: cited in two inspections, most seriously at level D.
How are weight and fluid intake tracked, and what happens when a resident starts losing weight?
Nutrition and Hydration: cited in two inspections, most seriously at level D.
What changed after F693 was cited, and how do you check it now?
Citation F693: cited in two inspections, most seriously at level D.
How is dialysis care coordinated, and who monitors residents before and after treatment?
Dialysis Care: cited in two inspections, most seriously at level D.
How are medication passes checked, and what happens when an error is found?
Medication Error Rate: cited in two inspections, most seriously at level E.
What happened after the medication error citation, and how are high-risk drugs double-checked?
Significant Medication Errors: cited in two inspections, most seriously at level E.
What changed after F921 was cited, and how do you check it now?
Citation F921: cited in two inspections, most seriously at level F.
How many nurses and aides are on each shift, including nights and weekends, for the unit we are considering?
No staffing citation appears in this window. Staffing levels are published separately by CMS and are worth asking about directly.
What led to the 2024 denial of payment, and what would you want a family to know about it?
Denial of payment was imposed December 13, 2024; it ended March 15, 2025.
The Evidence
Inspection results and penalties are published by the Centers for Medicare & Medicaid Services from surveys conducted by the Missouri state survey agency.
Missouri state survey agency
Inspection May 17, 2021 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
Missouri state survey agency
Inspection Dec 5, 2023 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
Missouri state survey agency
Inspection Dec 21, 2023 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
Missouri state survey agency
Inspection Jan 24, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
Missouri state survey agency
Inspection Apr 9, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
Missouri state survey agency
Inspection Dec 13, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
Missouri state survey agency
Inspection Jan 23, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
Missouri state survey agency
Inspection Feb 14, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
Missouri state survey agency
Inspection Mar 14, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
Missouri state survey agency
Inspection Aug 25, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
Missouri state survey agency
Inspection Nov 21, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
Missouri state survey agency
Inspection Feb 4, 2026 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
Missouri state survey agency
Inspection May 15, 2026 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
Centers for Medicare & Medicaid Services
Published Oct 1, 2026 · Retrieved Nov 1, 2026
Centers for Medicare & Medicaid Services · 265188
Published Oct 1, 2026 · Retrieved Nov 1, 2026
Record windowMay 17, 2021 – October 1, 2026
Historical coverage varies by agency and location. Missing records do not mean that no complaint or violation occurred.
Data architecture: Cierto supplies the source-backed machine-readable bundle. Life by Vardell independently creates the narrative, design, and consumer report.