Meadow View Health & Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Harrisonville, Missouri.
- Location
- 2203 East Mechanic Street, Harrisonville, Missouri 64701
- CMS Provider Number
- 265362
- Inspections on file
- 27
- Latest survey
- February 23, 2026
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Meadow View Health & Rehabilitation during CMS and state inspections, most recent first.
Surveyors found that kitchen refrigeration units lacked internal thermometers to verify safe food storage temperatures, while staff relied only on external gauges. In dry storage, several large dented cans of food were stored with other items instead of being separated as damaged goods. Inspectors also observed heavily scored cutting boards and a manual can opener with excessive greasy buildup and debris, indicating that food-contact surfaces were not maintained in a cleanable, sanitary condition. The Dietary Manager acknowledged that damaged foodstuffs should have been separated, cutting boards replaced when heavily scored, damaged items discarded, and the can opener cleaned after each meal, consistent with facility policy and food code requirements.
Multiple shower rooms were found with black mold-like or grime buildup, missing tiles, exposed building materials, and unclean toilets. Staff interviews revealed a lack of awareness and communication regarding these issues, and housekeeping had not been instructed to deep clean the affected areas. These deficiencies potentially affected all residents using the shower rooms.
A resident with quadriplegia and limited ROM did not receive necessary restorative therapy services due to staffing issues and lack of clarity among staff. Despite having an active order for therapy, the resident received only ten minutes of therapy over several weeks, as the facility had been without a Restorative Aide for months. Staff were unsure of who was responsible for ensuring the therapy was completed.
The facility failed to provide sufficient staffing to meet residents' needs, particularly on weekends, as shown in PBJ data. A resident with Alzheimer's was left in bed due to lack of staff, while another was left on the toilet for 25 minutes. Staff interviews revealed frequent understaffing, leading to unmet care needs and infrequent showers for residents.
The facility failed to maintain cleanliness and proper maintenance in the kitchen, affecting 87 residents. Issues included dust and grime buildup, damaged gaskets, insufficient spatulas, and improper milk temperature. Staff had to manually open trash lids, requiring frequent handwashing. The Dietary Director acknowledged these issues, noting pre-existing conditions and expectations for cleanliness.
The facility failed to maintain a clean environment, with dust and debris found in multiple resident rooms and common areas. Observations and interviews revealed that the housekeeping department was understaffed, leading to inadequate cleaning. Residents and staff reported insufficient cleaning due to time constraints, affecting at least 30 residents.
The facility failed to provide scheduled showers or baths for residents with severe cognitive and physical impairments, leading to deficiencies in personal hygiene care. Residents were often not bathed as scheduled due to understaffing and inconsistent documentation, with some going weeks without proper bathing. The lack of a dedicated bath aide and confusion over documentation processes contributed to the issue.
The facility failed to prepare broccoli properly, resulting in mushy and bland pureed broccoli due to incorrect ingredient use by an inadequately trained dietary staff member. Additionally, room trays were not maintained at the required temperature, with several residents reporting cold meals. The Dietary Director acknowledged the lack of processes for checking meal temperatures upon delivery.
The facility failed to maintain negative airflow in the restrooms of several resident rooms, affecting at least 20 residents. Observations showed no negative airflow in rooms 106, 102, 210, 209, 206/204, 205, 311/309, and 302/304. The Maintenance Director was unsure if the issue was related to electrical wiring and noted that some fans needed a bigger motor, with issues varying by hall.
A resident with dementia and a Stage II pressure ulcer had a low air loss (LAL) mattress set incorrectly at 200 pounds, despite weighing 130.8 pounds. Facility staff lacked training on adjusting LAL settings, and there was no physician order specifying the correct setting based on weight. The Wound Nurse monitored settings but did not document them, and the Assistant Director of Nursing acknowledged the need for settings to match the resident's weight. This deficiency was due to inadequate documentation and communication regarding LAL mattress settings.
A resident with a gastrostomy and multiple health issues frequently refused enteral feeding, but the LTC facility failed to accurately document these refusals or notify the physician. Despite the resident's distress and refusal, the Treatment Administration Record (TAR) did not consistently reflect these refusals, and the facility did not monitor the total formula intake per shift.
The facility failed to properly puree turkey for residents on pureed diets, resulting in a stringy texture. The dietary staff did not follow the recipe or taste the food before serving, as required. Interviews revealed that in-services for dietary staff were infrequent due to turnover and scheduling issues.
Food Storage, Equipment Sanitation, and Damaged Food Handling Deficiencies in Dietary Services
Penalty
Summary
Surveyors identified multiple food safety deficiencies in the facility’s kitchen related to storage, equipment condition, and sanitation. During kitchen sanitation inspections, refrigeration units labeled A, B, and C did not contain internal thermometers to verify that the external temperature gauges accurately reflected safe internal food storage temperatures. The [NAME] reported that staff relied solely on the external thermometers and did not verify temperatures with thermometers inside the units. In dry storage, surveyors observed several large canned food items with dents located on or just above the bottom rim, including cans of garbanzo beans, cream of mushroom soup, and chicken and dumplings, which were not separated from other foodstuffs as required by facility policy and state and FDA Food Codes. Surveyors also observed that several food-contact items and equipment were not maintained in a sanitary or safe condition. Red, white, and green cutting boards stored on a bottom shelf were heavily scored, contrary to FDA Food Code requirements that such surfaces be durable, smooth, easily cleanable, and either resurfaced or discarded when no longer effectively cleanable. A manual can opener across from the three-compartment sink had excessive greasy buildup and unknown debris and paper on it. In an interview, the Dietary Manager stated that damaged foodstuffs were supposed to be separated and returned to the vendor, cutting boards should have been replaced when heavily scored, damaged food preparation items were to be discarded and replaced, food was expected to be free of foreign substances, and the can opener was expected to be cleaned in the dishwasher after each meal. These observations and statements showed the facility did not follow its own food safety policy or applicable food code standards.
Failure to Maintain Clean and Safe Shower Rooms
Penalty
Summary
The facility failed to maintain resident shower rooms in a clean and safe condition, as evidenced by observations of black mold-like or grime buildup in the lower corners of shower walls and floors, missing baseboard and floor tiles, and exposed building materials in multiple shower rooms. Specific observations included a musty odor, large sections of missing floor tile, and unclean toilets with old brown substance splatter. These deficiencies were noted in the 200 hallway and memory care shower rooms, and potentially affected all residents using these areas, with a facility census of 82 residents. Interviews with staff revealed a lack of awareness and communication regarding the presence of mold and maintenance issues. Shower aides and CMTs were not aware of the extent of the mold or grime, while housekeeping staff acknowledged the presence of black mold-like buildup but had not been instructed to deep clean the shower rooms. The maintenance director was unaware of missing tiles or exposed wall materials and had only recently been notified of mold buildup under a shower mat. The administrator stated expectations for staff to report such issues but acknowledged that monitoring and maintenance had not been adequately performed.
Failure to Provide Restorative Therapy Services
Penalty
Summary
The facility failed to provide restorative therapy services to a resident with limited range of motion (ROM), which was necessary to prevent further decline in their condition. The resident, who was admitted with multiple spinal injuries and quadriplegia, was supposed to receive active assisted range of motion (AAROM) exercises three times a week. However, the resident did not receive any restorative therapy in the three months leading up to the survey, despite having an active order for such services. Interviews with the resident and staff revealed that the lack of restorative therapy was attributed to staffing issues, specifically the absence of a Restorative Aide. The resident expressed that they had not received the therapy and believed it was due to staffing shortages. Staff members, including a Certified Medication Technician (CMT) and a Licensed Practical Nurse (LPN), were unsure of the therapy services the resident was supposed to receive, and there was confusion about whether the resident had an active order for restorative therapy. The facility had been without a Restorative Aide since July or August, and there was uncertainty among staff about who was responsible for completing the restorative therapy in the aide's absence. The Assistant Director of Nursing (ADON) and other staff members were unclear about who should ensure the completion of restorative therapy, leading to the resident receiving only ten minutes of therapy over a period of several weeks. This lack of clarity and staffing issues resulted in the resident not receiving the necessary care to maintain or improve their ROM.
Insufficient Staffing Leads to Inadequate Resident Care
Penalty
Summary
The facility failed to ensure sufficient staffing numbers to consistently provide timely Activities of Daily Living (ADL) assistance for residents, particularly on weekends. The Payroll Based Journal (PBJ) data for the fourth quarter of 2023 and the first quarter of 2024 showed excessively low weekend staffing, which had the potential to affect all residents. The facility's staffing policy required sufficient numbers of staff with the necessary skills and competencies to provide care and services for all residents according to their needs. However, the facility's staffing schedules revealed significant gaps, particularly on the [NAME] Side, where there were instances of only one Certified Nurse Assistant (CNA) being scheduled for shifts that required more staff. Resident #77, who was severely cognitively impaired and dependent on staff for various ADLs, was observed lying in bed without assistance due to insufficient staffing. On one occasion, a Certified Medication Technician (CMT) was the only staff member on the Special Care Unit (SCU) from 7:00 A.M., and was unable to provide the necessary care for Resident #77, who required a two-person mechanical lift for transfers. Similarly, Resident #69, who required maximal assistance for showering and moderate assistance for transferring, reported being left on the toilet for 25 minutes during the night shift due to a lack of staff response to the bathroom call light. Interviews with staff members revealed that the facility often operated with minimal staffing, which was insufficient to meet the residents' needs. CNAs reported being unable to keep up with all the required cares during their shifts, and residents often did not receive showers or baths as scheduled due to staffing shortages. The Assistant Director of Nursing (ADON) confirmed that the facility's staffing assignment sheets should reflect the actual nursing staff working on any given shift, but the reported staffing levels did not meet the facility's minimum requirements. The Administrator was unaware of the low weekend staffing reported in the PBJ data, indicating a lack of oversight in addressing staffing deficiencies.
Deficiencies in Kitchen Maintenance and Food Safety
Penalty
Summary
The facility failed to maintain cleanliness and proper maintenance in the kitchen and food storage areas, which potentially affected 87 residents. Observations revealed a buildup of dust and debris under the refrigerator in the storage room, dust on sprinkler heads over the handwashing station and food preparation table, and greasy grime under the deep fat fryer. Additionally, the gasket of the reach-in refrigerator was held together with black tape, and the gasket of the walk-in freezer was in disrepair, causing the freezer not to close properly. Dust was also found on the ceiling vent over the clean side of the automated dishwasher, and debris was present in the nozzle of the upper spray wand. The handle of a spatula was melted and not easily cleanable, and there were not enough spatulas available for use. The dietary staff had to use their hands to open the trash container lid, requiring them to wash their hands each time they disposed of trash. The temperature of the milk served in the dining room was found to be 50 F, which is above the recommended 41 F. The Dietary Director (DD) acknowledged these issues during interviews, noting that the gasket had been taped before their employment and that the freezer's lever was not functioning properly. The DD also admitted to not checking the milk temperature in the dining rooms and expected staff to maintain cleanliness under the refrigerator and fryer. The DD was aware of the spatula handle issue but not of the specific spatula in question. The Dietary Manager (DM) expected cooks to check the temperatures of potentially hazardous foods.
Facility Fails to Maintain Clean Environment Due to Staffing Issues
Penalty
Summary
The facility failed to maintain a clean and safe environment for its residents, as evidenced by the heavy buildup of dust and debris in multiple resident rooms and common areas. Observations revealed dust accumulation on floors, fans, and ceiling vents in various rooms, including the 500 Hall shower room. Interviews with residents and staff indicated that the housekeeping department was understaffed, leading to inadequate cleaning practices. Residents reported noticing debris in their rooms, and staff confirmed that they were unable to clean thoroughly due to time constraints and insufficient personnel. The facility's housekeeping route sheet outlined an 8-step cleaning process, but the observations and interviews suggested that these steps were not consistently followed. The Maintenance Director and other staff members acknowledged the presence of dust and debris, attributing it to the limited number of housekeepers available. The report highlighted that at least 30 residents were potentially affected by these conditions, with a facility census of 88 residents. The deficiency was further corroborated by interviews with cognitively intact residents who expressed dissatisfaction with the cleanliness of their living spaces.
Inadequate Bathing Care and Documentation in LTC Facility
Penalty
Summary
The facility failed to ensure a consistent system for monitoring and providing showers or baths as scheduled for several residents, leading to deficiencies in personal hygiene care. Residents with severe cognitive impairments and physical disabilities, such as cerebral palsy and quadriplegia, were particularly affected. These residents were dependent on staff for all activities related to bathing and showering. Despite being scheduled for showers or baths twice a week, many residents received significantly fewer than scheduled, with some going weeks without proper bathing. Documentation was inconsistent, with missing records and unsigned shower sheets, indicating a lack of proper tracking and accountability. Resident #32, for example, was scheduled for showers twice a week but received only a fraction of the scheduled baths over several months. The resident's care plan indicated total dependence on staff for bathing, yet the facility failed to meet these needs consistently. Similarly, Resident #58, who was also severely cognitively impaired and dependent on staff, received fewer showers than scheduled, with family members stepping in to provide care when the facility did not. The lack of documentation and communication between staff and family members further exacerbated the issue. Interviews with staff revealed systemic issues, including understaffing and a lack of a dedicated bath aide, which contributed to the failure to provide adequate bathing care. Staff reported that residents were often not bathed as scheduled due to insufficient staffing, and there was confusion about the documentation process, which had recently transitioned from electronic to paper records. The Assistant Director of Nursing acknowledged the problem and mentioned a performance improvement plan, but the lack of a consistent system for tracking and ensuring showers were given remained a significant deficiency.
Deficiency in Food Preparation and Temperature Maintenance
Penalty
Summary
The facility failed to ensure that food and drink were palatable, attractive, and served at a safe and appetizing temperature. Specifically, the facility did not properly prepare broccoli florets, resulting in a mushy and overcooked texture. The dietary staff did not follow the recipe for pureed broccoli, using water instead of broth, which led to a bland taste. The dietary staff member responsible for preparing the pureed broccoli was new and had not been adequately trained, as evidenced by the lack of recipe book usage and incorrect ingredient substitution. The Dietary Director expected staff to taste the food for temperature and taste, but this was not consistently done. Additionally, the facility failed to maintain room trays at the required temperature, with food temperatures recorded significantly below the standard of 120 F at the time of service. Observations showed that food trays were not covered, and no one from the dietary department checked the temperatures of the room trays. Several residents reported that their meals were often cold, which made them feel less valued compared to those dining in the dining room. The Dietary Director acknowledged the lack of processes for checking meal temperatures upon delivery to residents and was aware of only a few complaints about cold food.
Failure to Ensure Negative Airflow in Resident Restrooms
Penalty
Summary
The facility failed to ensure negative airflow in the restrooms of several resident rooms, potentially affecting at least 20 residents. Observations conducted with the Maintenance Director and the Regional Maintenance Person revealed the absence of negative airflow in the restrooms of rooms 106, 102, 210, 209, 206/204, 205, 311/309, and 302/304. The airflow was tested by holding a piece of tissue paper to the ceiling vent; if the paper was not drawn up, negative airflow was absent. During a telephone interview, the Maintenance Director expressed uncertainty about whether the issue was related to electrical wiring and noted that some fans required a bigger motor. The issues affecting the fans varied for each hall.
Failure to Obtain Physician Order for LAL Mattress Setting
Penalty
Summary
The facility failed to obtain a physician order for the appropriate setting of a low air loss (LAL) mattress for a resident who developed a Stage II pressure ulcer. The resident, who was readmitted with dementia and was severely cognitively impaired, was receiving hospice services and was at risk for pressure ulcers. The physician's order indicated that the LAL mattress should be set for the resident's comfort, but did not specify a setting based on the resident's weight, which was 130.8 pounds. Observations showed the LAL mattress was consistently set at 200 pounds, which was not in accordance with the resident's weight. Interviews with facility staff revealed a lack of training and clarity regarding the appropriate settings for LAL mattresses. Certified Medication Technicians (CMTs) and Certified Nurse Assistants (CNAs) were not trained to adjust the LAL settings and were unaware of the need to set the mattress according to the resident's weight. The Wound Nurse monitored the LAL settings during wound treatments but did not document the settings. The Assistant Director of Nursing (ADON) acknowledged that the LAL mattress should be set as close as possible to the resident's weight and that the CMTs should report any discrepancies to the charge nurse or wound nurse. The deficiency was further compounded by the lack of documentation and communication regarding the LAL mattress settings. The Licensed Practical Nurse (LPN) interviewed was unsure how staff were supposed to set the LAL mattresses if the order indicated it should be set for comfort. The LPN also noted that there was no training provided on setting LAL mattresses, and the Treatment Administration Record (TAR) did not reflect checks on the mattress settings. This lack of clear guidance and documentation contributed to the failure to adjust the LAL mattress according to the resident's weight, potentially impacting the resident's skin integrity and comfort.
Inadequate Documentation of Enteral Feeding Refusal
Penalty
Summary
The facility failed to ensure accurate documentation of refusal of enteral feeding via a feeding tube for a resident at risk for weight loss due to declining health and refusal of treatment. The resident, who had a diagnosis of gastrostomy, protein-calorie malnutrition, dysphagia, and adult failure to thrive, was on enteral feedings but frequently refused the procedure. Despite the resident's refusal, the facility did not consistently document these refusals or notify the physician as required by their policy. The resident's care plan indicated the need for tube feeding due to dysphagia and poor intake, yet the facility's records showed multiple instances where the resident refused tube feeding and water flushes. Nursing notes documented the resident's distress and refusal to be connected to the feeding tube, but there were inconsistencies in the Treatment Administration Record (TAR) where refusals were not accurately coded or documented. The facility's Assistant Director of Nursing acknowledged that the documentation should have reflected the resident's refusal and that the physician should have been notified. Interviews with nursing staff revealed that the resident had been refusing tube feedings since the beginning, with the family initially requesting the tube feeding. The facility did not document or monitor the total amount of formula administered each shift, and there was no physician's order specifying the recommended amount of tube feeding formula intake in a 24-hour period. This lack of accurate documentation and communication with the physician contributed to the deficiency in care for the resident.
Improper Pureeing of Turkey for Residents on Pureed Diets
Penalty
Summary
The facility failed to properly puree turkey to a smooth texture, which potentially affected three residents on pureed diets. The recipe for pureed turkey required the turkey to be roasted, rested, and then pureed with a nutritive liquid until the desired consistency was achieved. However, during an observation, it was noted that the dietary staff member did not have the recipe book open and did not taste the pureed turkey for texture before serving it. The pureed turkey was found to be stringy, indicating it did not meet the required smooth texture. Interviews with the Dietary Director and the Consultant Registered Dietitian revealed that the cooks were expected to taste the pureed foods to ensure proper consistency. The Consultant RD mentioned that in-services for dietary staff were planned quarterly but occurred at least twice a year due to staff turnover and scheduling issues. This lack of adherence to the recipe and failure to taste the food before serving led to the deficiency in providing food prepared in a form designed to meet individual needs.
Latest citations in Missouri
Staff failed to protect a cognitively intact, independent resident from sexual abuse when a CNA repeatedly entered the resident’s room when the roommate was absent or asleep, hugged the resident, and kissed the resident on the mouth without the resident’s initiation or encouragement. A housekeeper observed the CNA return to the resident’s room, then saw the CNA and the resident in a full hug with the CNA kissing the resident on the mouth through a partially open door, and reported the incident. The resident later reported that these contacts were inappropriate and made the resident uncomfortable, while the CNA admitted to hugging the resident but denied kissing and believed hugging was not inappropriate, despite the facility’s abuse policy defining sexual abuse as any non-consensual sexual contact and requiring immediate reporting of abuse allegations.
Staff failed to report an allegation of sexual abuse to state authorities within the required two-hour timeframe after a cognitively intact resident with multiple psychiatric diagnoses reported being forced to touch another resident’s genitals in a dining room. A CNA observed the contact and notified an LPN, who separated the residents and obtained conflicting accounts, including a statement from the alleged victim that the act was forced. The facility’s investigation documented the allegation but did not show timely notification to the Department of Health and Senior Services, and state records confirmed the report was not made until more than 24 hours later. In interviews, the administrator stated the event was viewed as consensual and linked to the residents’ prior sexual history, while the LPN reported having informed the administrator the same day that the resident said the act was forced.
A resident with Alzheimer’s disease, severe cognitive impairment, and identified elopement risk was housed on a secured unit but was able to leave the building unnoticed when a floor tech exited through a coded door without ensuring it closed and no one followed. Staff last observed the resident near the nurses’ station and dining room, and when a CMT attempted to pass medications later, the resident could not be found, triggering a Code Pink and search. Multiple staff reported that the door alarm did not sound that night and that the door could be opened by pushing on it for several seconds or by using a code without an alarm. The facility’s investigation determined the door between the rehab and secured units was not securely closed after staff use, allowing the resident to elope and later be found in the community by EMS and transported to the ER without documented injury.
Facility staff did not fully develop or implement a comprehensive water management program to control Legionella and other waterborne pathogens. Although a written policy and an undated Water Management Plan existed, they lacked key elements such as a documented water management team, evidence of monthly monitoring review, documentation of baseline or annual Legionella testing, and specific guidance for identified high-risk areas like dead legs and unused bathrooms. Water temperature, pH, chlorine, and total dissolved solids were checked intermittently in random rooms without clearly identifying locations or consistently including all high-risk areas. The maintenance director reported flushing lines frequently but documenting checks only biweekly and not testing for Legionella, and was unfamiliar with the specific high-risk areas in the plan. Leadership, including the Regional Administrator, owner, and administrator, demonstrated limited knowledge of who performed Legionella testing, how the plan should be implemented, and the specific risk areas, control measures, and corrective actions required.
Staff failed to follow the facility’s emergency transfer/discharge policy when they discharged a resident to a local hospital for safety reasons and refused to allow the resident to return. The resident had been in the facility less than 24 hours, refused care, and made threats that scared staff, leading the administrator to authorize an immediate emergency discharge. Documentation included a progress note and an Immediate Discharge Notice listing the hospital as the discharge location for resident and staff safety, despite the administrator acknowledging that a hospital is not an appropriate discharge location. These actions resulted in the resident being discharged to a hospital without an appropriate emergency discharge notice that ensured the transfer met the resident’s needs/preferences and prepared the resident for a safe transfer/discharge.
A resident with significant GI history, chronic anemia, and recurrent constipation had physician orders and facility protocols requiring close bowel movement (BM) monitoring and a stepwise bowel regimen, as well as multiple medications for GI conditions, constipation, and other comorbidities. Staff failed to consistently document BMs, did not implement ordered bowel interventions when BMs were absent for several consecutive days, and delayed notifying the physician until the resident had gone multiple days without a BM and developed coffee‑ground emesis, leading to hospital evaluation where fecal impaction and stercoral colitis were documented. The care plan was not updated to reflect increased BM monitoring after a prior hospitalization for constipation/impaction, and the TAR showed missed documentation of ordered BM checks. In addition, the MAR showed repeated refusals of numerous medications throughout the month, including GI, cardiac, constipation, and psychiatric drugs, yet there was no documentation that the physician was notified of these frequent refusals, despite facility policy requiring reporting of medication refusals.
Surveyors found that the facility failed to keep call lights within reach for two residents, despite a policy requiring accessible call lights and frequent checks for those unable to use them. One resident, with multiple medical conditions, an above‑knee amputation, moderate cognitive impairment, and a history of numerous falls, was repeatedly observed asleep in a wheelchair by the bed with the call light on the floor or under the bed, and the care plan did not address the resident’s falls or related interventions. Another resident with Alzheimer’s disease, dementia, contractures of all extremities, and hospice care needs was observed lying in bed with the call light at the foot of the bed or under the bed, out of reach, even though the care plan specified the call light should be within reach. Staff, including an LPN, a CNA, the Administrator, and the DON, all stated that call lights should always be within reach for all residents, and that frequent rounding was expected when residents could not use the call light, confirming that practice did not align with stated expectations.
A non-verbal resident with severely impaired cognition and total dependence for ADLs was seated in a WC with an arm looped around the WC handle when a CNA/restorative aide repeatedly attempted to reposition the arm to the front. Despite the resident’s non-verbal refusals and resistance, the aide pried the resident’s fingers from the WC wheel, grabbed the arm, and forcefully jerked it forward, causing the resident’s body to lurch and nearly fall from the chair. Video review showed the aide tugging and pulling on the arm multiple times as the resident refused further assistance, and a staff witness reported the aide was yelling and grabbing at the resident while the resident fought to get free. The resident later stated staff were rough and that he/she was afraid. These actions, inconsistent with the resident’s care plan and the facility’s abuse policy, resulted in a finding that the resident was subjected to physical abuse.
Two residents with significant risk factors for skin breakdown did not receive consistent, accurately documented wound care. One resident with multiple comorbidities and existing pressure-related wounds had no skin or wound interventions on the care plan, lacked an EMR order for a newly identified ankle wound, and had numerous missed or undocumented treatments for buttocks, hip, and ankle wounds, including barrier creams and Medi Honey applications. Another high-risk resident with a low Braden score had no skin-related care plan, an ankle wound that was reported as healed while MAR/TAR entries continued, weekly skin checks documented as normal despite an active ankle dressing, and a right ankle wound that went unreported in shift report until surveyors observed an outdated dressing; subsequent documentation by the wound specialist and facility conflicted on the wound’s type and measurements. The DON later confirmed expectations that staff follow wound policies, enter and document orders and refusals in the EMR, and update care plans, which were not met in these cases.
The facility failed to implement and document effective fall interventions for a resident with an above‑knee amputation, lower extremity impairment, and a history of multiple witnessed and unwitnessed falls related to attempting independent transfers. Although the care plan noted general assistance needs, it did not address the repeated falls or specify individualized fall‑prevention measures, and fall investigations recorded no new interventions despite ongoing events. Surveyors observed the resident in a wheelchair by the bed multiple times with the call light out of reach on the floor. In addition, the facility did not complete a required smoking safety assessment for a resident with Huntington’s disease, weakness, and moderately impaired cognition, even though this resident was observed smoking outside and facility policy required a smoking assessment at admission to determine needed supervision.
Failure to Protect a Resident From Non-Consensual Sexual Contact by CNA
Penalty
Summary
Facility staff failed to protect a cognitively intact resident from sexual abuse when a CNA engaged in non-consensual physical contact. The resident’s quarterly MDS showed the resident was cognitively intact and care plan indicated independence with ADLs. On the morning in question, a housekeeper observed the CNA go to the nurses’ station from the direction of the resident’s room, look around, then quickly return to the resident’s room. When the housekeeper approached to clean the room, the door was slightly open; after a quiet knock and looking in, the housekeeper saw the CNA and the resident in a full hug, with the CNA kissing the resident on the mouth. The housekeeper then reported this observation to another housekeeper, who in turn reported it to the administrator. The facility’s abuse and neglect policy defined sexual abuse as non-consensual sexual contact of any type with a resident and required immediate reporting of all abuse allegations to the administrator. In a written statement, the CNA acknowledged going to the resident’s room and hugging the resident, claiming it was to comfort the resident, and denied kissing the resident, stating that hugging residents was not considered inappropriate. In contrast, the resident documented and later stated in interviews that the CNA had repeatedly come into the room when the roommate was absent or asleep to hug and kiss the resident, that these actions were not initiated or encouraged by the resident, and that the resident felt uncomfortable and did not want to be kissed. The resident also reported not disclosing these incidents earlier due to concern about how the CNA might treat the resident and the resident’s friends.
Failure to Timely Report Allegation of Sexual Abuse to State Authorities
Penalty
Summary
Facility staff failed to report an allegation of sexual abuse to the Department of Health and Senior Services (DHSS) within the required two-hour timeframe. The facility’s abuse, neglect, exploitation, and misappropriation prevention program, revised April 2021, states staff will identify and investigate all possible incidents of abuse, neglect, mistreatment, or misappropriation of resident property and report any allegations within timeframes required by federal requirements. Resident #1, assessed as cognitively intact on a quarterly MDS dated 2/12/26, had diagnoses including schizoaffective disorder, bipolar type, major depressive disorder, generalized anxiety disorder, and bipolar disorder. On 3/29/26, CNA A reported to LPN B that Resident #1 was seen touching Resident #2’s privates in the main dining room; CNA A separated the residents, and LPN B interviewed both residents. Resident #1 stated Resident #2 forced him/her to touch his/her privates, while Resident #2 denied the allegation. The facility’s investigation, dated 3/30/26, documented that Resident #1 reported assisting Resident #2 in playing with his/her privates but stated he/she was forced to assist. The investigation record did not show that facility staff contacted DHSS within the required two-hour timeframe after the allegation was reported. Review of the DHSS database confirmed that the facility did not report the allegation of sexual abuse until more than 24 hours after Resident #1 made the allegation. During interviews, the administrator stated he/she would have reported within two hours if the act was not consensual and claimed he/she was not informed that Resident #1 said he/she was forced until 3/30/26, characterizing the situation as involving residents with a past sexual history who were upset because they were caught. However, LPN B stated that on 3/29/26 at 10:12 A.M. he/she called the administrator and explained in detail that Resident #1 said he/she was forced into the sexual act, and that the administrator responded that the residents had a sexual history, so it was okay.
Failure to Secure Door and Supervise Wanderer Resulting in Elopement
Penalty
Summary
The deficiency involves the facility’s failure to ensure a secured unit door was properly secured and supervised, allowing an at-risk resident to exit the building unnoticed. The resident had Alzheimer’s disease, an anxiety disorder, hearing loss, and was assessed as severely cognitively impaired on the MDS. An Elopement Risk Evaluation identified the resident as ambulatory, wandering aimlessly, and at risk for elopement, and the care plan documented that the resident was on a secured unit with impaired cognitive function. Despite this, the resident was last seen around the nurses’ station and dining room in the early evening and was not continuously monitored in a way that prevented unsupervised access to an exit door. On the evening of the incident, staff reported seeing the resident around 8:00–8:10 p.m. near the nurses’ station and dining room. A CMT later attempted to pass medications to the resident at approximately 8:30 p.m. and discovered the resident was not in their room, prompting a Code Pink and an internal search of the unit and facility. Staff, including the CMT and CNA, reported that the door alarm did not sound the night the resident left, and that previously the door could be opened by pushing on it for several seconds, or by using a code, without an alarm sounding. The Administrator and DON stated that prior to the elopement, the doors were configured so that pushing and holding the bar for 15–20 seconds would open the door and trigger an alarm, but staff did not hear an alarm at the time of the incident. A floor tech working on the secured unit acknowledged exiting through the coded door between the rehab and secured units during the relevant time frame and not checking whether anyone was following or whether the door clicked shut behind them, despite prior training to watch the door for residents attempting to leave. The facility’s investigation concluded that the entry door to the facility was not securely closed after staff exited the unit, creating an opportunity for unauthorized egress, and determined that the resident exited through the door between the rehab and secured unit. The resident was later found by EMS approximately 1.5 miles from the facility, wandering and only alert to self, and was transported to the hospital, where no injuries were documented. The nurse practitioner noted the resident was a wanderer, fairly new to the facility, and expected staff to check on the resident every one to two hours.
Incomplete Legionella Water Management and Monitoring Program
Penalty
Summary
Facility staff failed to develop and implement complete policies and procedures for inspection, testing, and maintenance of the facility’s water systems to inhibit the growth of waterborne pathogens, including Legionella. CMS guidance (QSO-17-30) requires certified healthcare facilities to have water management policies and procedures, including a facility risk assessment, a water management program aligned with ASHRAE standards and CDC toolkit, specified testing protocols with acceptable ranges and documentation of results and corrective actions, and compliance with applicable regulations. The facility’s Legionella Infection policy, dated 03/05/20, stated these requirements but the actual implementation and supporting documents did not meet them. Review of the facility’s Water Management Plan showed it included a risk assessment that identified several high-risk areas, such as dead legs in specific rooms and departments, empty resident room bathrooms, and low-rise floor sinks in housekeeping closets. The plan stated that environmental testing would be conducted if there was difficulty maintaining water systems within control limits or if a healthcare-associated Legionella case occurred, and it instructed staff to perform baseline Legionella testing at four specified sites. However, the plan lacked a list of designated water management team members, documentation of monthly review of scheduled monitoring, documentation of baseline or annual Legionella testing, and specific guidance related to the identified high-risk areas. The facility’s Infection Prevention and Control Program, dated 04/10/19, did not contain information related to Legionella. Record review of the Resident Room Water Temperature and Checklist for a three-month period showed staff tested water temperatures in random resident rooms on both wings and also tested water pH, chlorine, and total dissolved solids, but did not indicate the testing locations or include results for all identified high-risk areas. In interviews, the maintenance director reported flushing resident room water lines almost daily but only documenting water checks every two weeks, testing pH and chlorine every two weeks, and not testing for Legionella; the director was familiar with the water management plan only generally and was not familiar with the specific high-risk areas. The Regional Administrator stated the facility should have annual Legionella testing but did not know who conducted it. The owner indicated that corporate maintained a template Water Management Policy but that the facility administrator was responsible for developing and implementing a facility-specific plan. The administrator stated the water management plan should include how water is tested monthly, believed Legionella testing was only done if there was suspicion or a positive case, had not updated the plan since an earlier review, did not document the water management team membership, had not discussed the plan with the maintenance director, and was not familiar with specific risk areas, control measures, or corrective actions.
Improper Emergency Discharge to Hospital and Refusal to Readmit Resident
Penalty
Summary
Facility staff failed to provide an appropriate emergency discharge notice and improperly discharged a resident to a hospital while refusing the resident’s return. The facility’s policy on making an emergency transfer or discharge, revised April 2007, directed staff to only make an emergency discharge when it is in the best interest of residents and to follow specific procedures, including notifying the attending physician and receiving facility, preparing the resident and a transfer form, notifying the representative and family, and assisting with transportation. Record review showed the resident was admitted on 3/3/26 and discharged to the hospital the same day, with a progress note the following day documenting an emergency discharge effective immediately to the local hospital for safety reasons. An Immediate Discharge Notice dated 3/3/26 listed the local hospital as the discharge location for resident and staff safety. In an interview, the administrator stated the resident had been in the building less than 24 hours, had refused care, made threats, and scared staff, and that an emergency discharge to the hospital was done that day; the administrator acknowledged that a hospital is not a discharge location but stated the facility would not take the resident back for the safety of staff and other residents. These actions and documentation show that staff used the hospital as the discharge location and refused readmission, contrary to the facility’s own emergency transfer/discharge policy and without providing an appropriate emergency discharge notice that ensured the transfer/discharge met the resident’s needs and preferences and prepared the resident for a safe transfer/discharge.
Failure to Monitor Bowel Function and Report Repeated Medication Refusals
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care according to physician orders, facility bowel protocol, and the resident’s care needs, specifically related to bowel monitoring, constipation management, and medication refusals. The facility’s own Medication Monitoring policy required licensed nurses to report refusals of medications and to identify interventions on the care plan for systematic monitoring of high‑risk medications. The Bowel Protocol required routine monitoring and documentation of bowel movements (BMs), use of a stepwise regimen (milk of magnesia on day three without a BM, bisacodyl suppository on day four, and fleet enema on day five), and prompt provider notification of significant changes such as impaction. For one resident with significant GI history and prior constipation/impaction, staff did not consistently document BMs, did not follow the bowel protocol when BMs were absent for multiple days, and did not notify the physician in a timely manner. The resident had a history of chronic GI blood loss, recurrent constipation, large stool burden, and prior fecal impaction. In mid‑November, the resident was hospitalized for anemia, GI bleeding, and severe constipation with a large fecal impaction, during which a disimpaction was performed and the physician recommended keeping a record of BMs. After return, facility bowel elimination records showed multiple gaps in documentation and prolonged periods without recorded BMs. In early December, there were days with no documentation and no recorded BMs, and staff did not document physician notification or administration of bowel interventions from several consecutive days without BMs. Later in December, the record again showed multiple consecutive days with no BMs documented; staff did not administer bowel interventions until the sixth day and did not document physician notification until that time. A nurse’s note on that day described the resident having no BM for five to six days, vomiting coffee‑ground emesis, and being sent to the hospital, where hospital records documented stercoral colitis, fecal impaction, and a moderate to large amount of stool throughout the colon. Despite the resident’s history and the physician’s expectation for close monitoring, the February Treatment Administration Record showed an active order to monitor BMs daily with a requirement that the resident have a BM every other day and to give a Dulcolax suppository if no BM every other day, yet nursing staff failed to document monitoring on multiple shifts. The resident’s care plan did not reflect the increased BM monitoring ordered after the hospitalization for constipation/impaction. Interviews with RNs, LPNs, CNAs, the MDS coordinator, ADON, DON, and the physician showed inconsistent understanding and implementation of the bowel protocol and monitoring orders; staff acknowledged that monitoring had not been consistent and that the system for tracking BMs was not effective. The deficiency also includes failure to notify the physician of multiple medication refusals for this resident. Throughout February, the MAR showed repeated refusals of numerous ordered medications, including baclofen, bisacodyl, Carafate, Colace, Dexilant, ferrous sulfate, folic acid, metoprolol, Miralax, pravastatin, Remeron, and Senna‑S, often refused more than ten times in the month. The facility’s Medication Monitoring policy required nurses to report refusals of medications to the physician, but the medical record contained no documentation of physician notification regarding these repeated refusals. Nursing staff and the MDS coordinator acknowledged that the resident refused medications and that they used nursing judgment about when to notify the physician, but several staff did not know how many refusals should trigger notification, and some believed the physician was aware without recalling specific contacts or documentation. The physician stated that he knew the resident sometimes refused medications but was not aware of the high frequency of refusals in February and stated he wanted to know when refusals occurred so often. Overall, the actions and inactions leading to the deficiency included failure to consistently document and monitor BMs per order and protocol, failure to implement ordered bowel interventions when BMs were absent for multiple days, failure to update the care plan to reflect increased bowel monitoring after hospitalization for constipation/impaction, and failure to notify the physician of frequent medication refusals as required by facility policy. These failures occurred despite the resident’s known history of GI bleeding, recurrent constipation, fecal impaction, and prior hospitalizations for GI issues and constipation.
Failure to Keep Call Lights Within Reach for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to reasonably accommodate residents’ needs and preferences by not ensuring call lights were within reach, contrary to its own “Answering the Call Light” policy. That policy required staff to keep call lights within easy reach for residents in bed or confined to a chair and to frequently check residents unable to use the call light. Despite this, surveyors observed multiple instances where residents’ call lights were out of reach or on the floor, and staff interviews confirmed that the expectation was for call lights to be accessible at all times when residents were in their rooms. One resident had diagnoses including type 2 diabetes, acute kidney failure, and an above-knee amputation, with cognition changing from intact on admission to moderately impaired on a subsequent MDS. The resident’s care plan addressed admission for LTC, need for assistance with bed/chair mobility, transfers, and locomotion, and use of a wheelchair with safety reminders, but did not address the resident’s multiple falls or any fall interventions. Facility event reports documented numerous falls, both witnessed and unwitnessed, over a three‑month period. During several observations on different days and times, this resident was seen asleep in a wheelchair by the bed, with the call light out of reach—on the ground on the opposite side of the bed or under the bed—despite staff acknowledging the resident fell frequently and liked to sleep in the wheelchair. Another resident had diagnoses including Alzheimer’s disease and dementia, was unable to communicate, and had all four extremities contracted. The care plan identified risk for dehydration and increased pain due to contractures, skin integrity issues, and hospice care, with specific interventions to keep the call light within reach and remind the resident to call for assistance. However, during multiple observations, this resident was lying in bed with the call light positioned at the foot of the bed or on the floor under the bed, out of reach. Staff, including an LPN and a CNA, stated that call lights should be within reach for all residents regardless of cognitive status and that frequent rounding was expected if a resident could not use the call light. The Administrator and DON also stated they expected call lights to be in reach for all residents at all times and specifically for residents with frequent falls, underscoring that the observed conditions did not meet facility expectations or policy.
Resident Physically Abused During Forceful Arm Repositioning
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from physical abuse and to honor the resident’s right to be free from the willful infliction of physical harm. The facility’s abuse policy defined abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment resulting in physical harm, pain, or mental anguish, and required staff training in abuse prevention and sensitivity to residents’ rights and needs. The policy also required that all incidents, allegations, or suspicions of abuse be documented and investigated. Despite these policies, a staff member, identified as Restorative Aide/CNA E, used excessive force while attempting to reposition a resident’s arm, in a manner inconsistent with the resident’s care plan and the facility’s abuse prevention standards. The resident involved had severely impaired cognition, unclear speech, and was non-verbal, with dependence on staff for all ADLs, and weighed 213 lbs. The resident’s care plan identified impaired communication and decision-making, with approaches that included explaining procedures prior to tasks, providing cues and reorientation, offering simple choices, and using alternative communication methods as needed. On observation, the resident was seated in a wheelchair at the nurse’s desk with his/her arm positioned on the back of the wheelchair and looped around the handlebar. Restorative Aide/CNA E stood to the right of the resident and repeatedly attempted to move the resident’s right arm forward. The resident responded with non-verbal refusals, moving the arm away and then propelling slightly forward to grasp the wheelchair wheel. Despite these non-verbal refusals, Restorative Aide/CNA E pried the resident’s fingers off the wheelchair wheel, grabbed the resident’s right arm with one hand while placing the other hand behind the triceps area, and forcefully jerked the arm forward. This action caused the resident’s seated body to lurch forward to the point that the resident nearly fell out of the wheelchair onto the tile floor. A subsequent observation showed the aide wiping the resident’s hands with a washcloth that had a red substance on it. Shortly afterward, the resident, when interviewed, stated that staff were rough and that he/she was afraid. Review of security camera footage with facility leadership showed the aide tugging and pulling on the resident’s arm in a forward motion multiple times, with the resident refusing further assistance and the aide becoming more aggressive. A laundry assistant also reported seeing the aide yelling and grabbing at the resident, with the resident resisting and fighting to get the aide off, and believed the incident affected the resident’s behavior afterward. These observed and documented actions constituted the use of excessive force and physical abuse toward the resident. Additional interviews further described the context of the incident. Restorative Aide/CNA E stated that the resident liked to sit with the arm behind the chair and claimed to be repositioning the arm at the resident’s request, acknowledging that the resident’s hand was locked on the wheelchair wheel and that the aide moved it off. The aide reported the resident complained of arm pain and that a red substance seen on the arm was ketchup from lunch, and did not believe the handling was rough. In contrast, an LPN who had cared for the resident for three months stated the resident commonly rested the arm behind the wheelchair, had never required arm repositioning for that posture, and had not complained of arm pain in that position. Facility leadership, after viewing the video, agreed that the staff member used excessive force and that the aide should have stopped and re-approached the resident instead of continuing to pull and tug on the arm in the face of resistance. These facts collectively demonstrate that the resident’s right to be free from physical abuse was not upheld.
Failure to Provide Consistent Wound Care and Accurate Skin Assessment Documentation
Penalty
Summary
The deficiency involves the facility’s failure to provide consistent wound treatments, timely and accurate wound orders, and accurate skin assessments for two residents with wounds. For one resident with multiple comorbidities including open right foot wound, coccyx pressure ulcer, stroke, hemiplegia, dysphagia, severe protein-calorie malnutrition, seizures, and peripheral vascular disease, the care plan in use during the survey contained no problems, goals, or interventions related to skin or wound prevention, despite these conditions. A readmission skin observation documented no abnormalities, but shortly afterward an NP note identified a new open area to the right ankle and ordered cleansing and Medi Honey treatment. The corresponding physician orders reflected Medi Honey treatment to the right buttocks, but there was no EMR order for the right ankle wound treatment on the MAR/TAR. Multiple subsequent skin observation reports and wound doctor notes documented MASD and a stage 3 right hip pressure injury with specific measurements and treatment orders, yet the documentation of wound locations was sometimes incomplete or inconsistent. Medication and treatment administration records for this resident showed numerous missed or undocumented wound care treatments. The December and January MAR/TARs reflected missed opportunities for Medi Honey and right hip dressing changes, including refusals without required progress notes and missed treatments without explanation. In February, barrier cream and zinc oxide orders for the peri area and buttocks were documented as missed in all or many opportunities, and wound treatments to the right buttocks, right hip, and right ankle were missed multiple times without progress notes. A new ankle wound was noted by the DON, with an NP confirming the resident did not need hospital evaluation and suggesting continuation of the wound doctor’s plan, and later documentation described a right ankle/foot stage 2 ulcer with specific measurements. However, the EMR showed missed treatments for the ankle wound and the facility’s wound report later listed multiple MASD sites (right buttocks, coccyx, groin) with onset dates and durations, indicating these wounds were not present on admission but had remained open for extended periods. For a second resident with morbid obesity, bipolar disorder, and intellectual disability, the annual MDS showed no skin concerns, and the care plan in use during the survey contained no skin-related problems, goals, or preventive interventions, despite a Braden score of 11 indicating high risk for pressure injury. Physician orders included offloading pressure areas on the heels and elevating extremities every shift, as well as an order to cleanse the right lateral ankle and apply a foam dressing every three days. Wound specialist notes indicated the resident was not seen on two occasions, once due to being away with family and once because the DON reported the right ankle wound as healed. Weekly skin observation reports in March documented no skin abnormalities, yet the March MAR/TAR showed ongoing documentation of right ankle dressing changes and refusals. On observation, the resident had a foam dressing on the right ankle dated several weeks earlier, and the LPN acknowledged the outdated dressing, stated night shift was scheduled to change it, and then discovered in the EMR that the resident was listed as refusing care over a prolonged period, although the LPN was unaware of the wound and it had not been mentioned in shift report. The wound measured 2 cm by 2 cm at that time, and the DON later described discoloration to the left heel and stated he could not make clinical decisions on staging without the wound doctor. A wound specialist note that same day identified a new stage 2 pressure injury over the right ankle with specific measurements and treatment orders, while the facility’s wound report listed the same area as an abrasion with different initial measurements, demonstrating inaccurate and inconsistent documentation of the wound’s status and type. The DON stated that nursing staff were expected to follow facility policies, that weekly assessments were completed but not ordered, and that staff were prompted in the EMR scheduler. The DON explained that shift nurses were expected to enter treatment orders or provide them to the DON to enter, that nurses were expected to document progress notes when residents declined treatments, and that the medical doctor should be notified of new hospital wound treatment recommendations. The DON also stated that care plans should be updated within 24–48 hours to reflect new changes and that staff should attempt a second approach or allow time before documenting a refusal. Despite these expectations and the facility’s wound management policy requiring Braden assessments, daily or weekly skin checks based on risk, accurate wound differentiation and documentation, and consistent use of wound protocols, the records for both residents showed failures to consistently administer ordered treatments, failures to enter and maintain accurate wound treatment orders in the EMR, and failures to accurately document skin assessments and wound characteristics needed for appropriate follow-up and monitoring.
Failure to Implement Fall Interventions and Complete Smoking Safety Assessment
Penalty
Summary
The deficiency involves the facility’s failure to maintain an accident‑hazard‑free environment and to provide adequate supervision and interventions to prevent accidents, specifically falls and unsafe smoking. For one resident with lower extremity impairment, an above‑knee amputation, diabetes, and acute kidney failure, the admission MDS showed a need for partial to moderate assistance with transfers and use of a wheelchair. The resident’s care plan addressed general needs for assistance with bed/chair mobility, transfers, and locomotion, and noted the need for monitoring to prevent falls, but it did not address the resident’s actual history of multiple falls or specify any individualized fall interventions. Facility event reports documented numerous falls over several months, including unwitnessed and witnessed falls in the bathroom and room, often related to the resident attempting independent transfers from wheelchair to toilet or from bed to wheelchair without assistance. Fall investigations dated across this period identified root causes such as the resident leaving the dining area and attempting to transfer independently in a common bathroom, and attempting to get out of bed and into a wheelchair without assistance despite having an amputated leg. These investigations documented that the resident was encouraged or educated to ask for help or call for assistance, but no new interventions were recorded following these events. Observations by surveyors showed the resident seated in a wheelchair by the bed with eyes closed on multiple occasions, with the call light not in reach and at times on the floor on the opposite side of the bed. The Director of Therapy stated the resident was receiving PT, OT, and speech therapy and recommended a wedge (tilt‑in‑space) wheelchair with foot pedals, more frequent rounding, and ensuring the call light was in reach, and expected these interventions to be reflected on the care plan. An LPN and facility leadership acknowledged the resident had frequent falls and that interventions, including those tried such as frequent rounding and ensuring call light access, should have been documented on the care plan. The deficiency also includes failure to assess another resident for smoking safety. This resident had diagnoses including Huntington’s disease and weakness, with moderately impaired cognition documented on the admission MDS. Review of the electronic medical record showed no smoking assessment, despite the facility’s smoking policy requiring assessment at admission and at least quarterly or with significant change to determine needed assistance and supervision. Surveyor observations documented this resident smoking outside on more than one occasion. An LPN, the Administrator, and the DON all stated that a smoking assessment should have been completed upon admission to ensure the resident’s safety while smoking, but no such assessment was found in the record.
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