Average — CMS composite of the measures below.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
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.
The facility failed to maintain a comprehensive infection prevention and control program for Legionella and other water-borne pathogens, with incomplete and disorganized Legionella tracking materials, no facility-specific risk assessment, no completed CDC environmental assessment, and no outbreak plan. The facility also failed to ensure proper hand hygiene during med pass and blood glucose/insulin care: an LPN and an RN entered resident rooms without cleaning hands appropriately, wore gloves in ways that created cross-contamination concerns, and performed medication and insulin tasks without hand hygiene between residents or between different routes of administration.
Improper storage of expired and unlabeled medications and supplies was found in two medication carts and one medication storage room. Surveyors observed expired suppositories, saline, wound dressings, vitamin supplements, and other medical items, along with an EpiPen removed from its original container and lacking a label and expiration date. Staff interviews confirmed that expired or improperly stored items should not remain in carts, and the DON stated cart checks were done monthly without a check-off list.
A facility failed to ensure required orders and an assessment were in place for self-administration of medications. One resident with COPD was given a Symbicort inhaler to use but had no self-administration order or assessment, and the resident used it incorrectly without rinsing the mouth. Another cognitively intact resident had bedside eye drops and an albuterol inhaler without orders for those medications or for self-administration, and the resident reported using them without informing staff. Staff interviews confirmed that orders and an assessment were needed for self-administration.
A resident with COPD and chronic respiratory failure had a BiPAP order at night and continuous oxygen via NC, but observations showed the BiPAP mask laying on clothing and the NC wrapped around the wheelchair handles instead of being stored in a dated plastic bag. Staff stated the respiratory items were supposed to be kept in plastic bags when not in use and that the resident was noncompliant with storage of the equipment.
Failure to Address Trauma-Related Needs in Care Plans: The facility did not identify, assess, or provide supportive interventions for two residents with trauma-related needs. One resident had PTSD with repeated trauma screening findings and reported no staff had asked what worsened or improved symptoms, while the other had suspected abuse diagnoses and positive trauma screenings with anxiety around unknown males and a preference to avoid crowds. In both cases, staff were unfamiliar with the residents’ triggers and the care plans did not include trauma-related triggers or interventions.
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.
Infection Control Program and Hand Hygiene Failures
Penalty
Summary
The facility failed to establish and maintain a comprehensive infection prevention and control program for Legionella and other water-borne pathogens. Review of the water-borne pathogen prevention paperwork in the binder titled Legionella - Water Tracking for the Facility showed 10 numbered tabs that were unlabeled and not referenced, no table of contents page, an empty Tab #4, and a PowerPoint in Tab #7 that was missing the first 14 slides. The record also showed there was no facility-specific risk assessment that considered ASHRAE standard #188, no completed CDC Legionella Environmental Assessment Form, and no facility-specific infection prevention program or plan to deal with outbreaks of Legionella and/or other waterborne pathogens. The facility environment included multiple water sources and fixtures throughout the building, including two main water pipes entering through the basement fire sprinkler riser room, a complete fire sprinkler system, public restrooms, medication room sinks, resident room bathrooms and sinks, housekeeping closets with mop/service sinks, boilers, hot/cold water piping, commercial laundry washers, bathhouses with showers, and a beauty shop sink. The Director of Maintenance stated the program already existed when he/she was hired, that monthly testing had been added, and that empty rooms were checked weekly and faucets ran for a while, though this was undocumented. The Administrator stated he/she had been educated on Legionella prevention requirements through administrator trainings, studying for exams, and a preceptor. The facility also failed to ensure appropriate hand hygiene during medication administration and blood glucose/insulin care for four residents. One resident with DM II received topical Voltaren Gel and oral medications from an LPN who did not wash or sanitize hands before starting, wore gloves into the room, removed gloves after applying the gel, and then gave oral medication without hand hygiene before exiting. A second resident with Huntington's Disease received PRN acetaminophen from the same LPN, who did not wash or sanitize hands before starting or after giving the medication. A third resident with COPD and Parkinson's Disease received multiple medications from the same LPN, who did not wash or sanitize hands before starting, entered and exited the room multiple times without hand hygiene, and handled the resident's blood pressure check and medication preparation without cleaning hands between tasks. A fourth resident with DM II had blood glucose checked and insulin administered by an RN who entered the room wearing gloves, kept the same gloves on while handling supplies and checking blood sugar, set the glucometer on the bedside table, put gloved hands in a pocket, and then administered insulin with the same gloves.
Improper Storage of Expired and Unlabeled Medications and Supplies
Penalty
Summary
The facility failed to ensure appropriate medication and medical equipment storage in two of five medication carts and in one of two medication storage rooms. The cited issue involved expired medications and supplies, medications not stored in their original containers, and items with missing or improper labeling. Facility policies stated that drugs and biologicals were to be stored in the packaging or dispensing systems in which they were received, that medications could not be transferred between containers, and that discontinued, outdated, or deteriorated drugs or biologicals were to be returned to the pharmacy or destroyed. On observation of the 400/500 hall nurse cart, surveyors found 12 hemorrhoidal suppositories expired in September 2025, seven hemorrhoidal suppositories expired in December 2025, a 100 ml bottle of sterile 0.9% normal saline expired on 1/1/26, two wound dressings expired on 7/24/25, and one wound dressing expired in May 2022. On observation of the 200-hall nurse cart, surveyors found three hemorrhoidal suppositories expired in September 2025, one EpiPen not stored in its original container with no label and no expiration date visible, one decannulation plug expired on 11/20/25, one bottle of vitamin supplements expired in July 2025, one opened spray bottle of hydrogen peroxide topical solution with no expiration date, one urinary drainage bag opened and missing a cap with no expiration date visible, one tracheostomy inner cannula 5.0 mm with a use-by date of 12/16/25, and one enteral funnel transition connector expired on 7/26/25. In the west side medication room, surveyors observed one bottle of supplements with a cracked and broken lid. During interviews, the CMT, LPN, and DON stated that expired medications and supplies should not be stored in medication carts, that medications needed to remain in their original containers, and that improperly stored or mislabeled items should be disposed of. The DON also stated that nurse management checked carts monthly and that the pharmacist only checked a couple of carts when visiting, with no check-off list or sheet completed during cart checks.
Self-Administration of Medications Without Required Orders and Assessment
Penalty
Summary
The facility failed to ensure orders were in place for self-administration of medications for two residents and failed to ensure a self-administration assessment was in place for one resident. The deficiency involved Resident 47, who was admitted with COPD and was cognitively intact on the quarterly MDS, and Resident 81, who was cognitively intact on the quarterly MDS and had orders for PRN albuterol inhaler use. Facility policy stated that if self-administration was deemed safe and appropriate, it would be documented in the medical record and care plan, and that an assessment of cognitive and physical abilities would be completed to determine whether self-administration was clinically appropriate. For Resident 47, the record showed an order for Symbicort inhalation aerosol, but no order related to self-administration of the inhaler was found. During observation, an LPN handed the resident the inhaler, and the resident attempted to use it but administered it incorrectly and did not rinse the mouth after use. The resident stated that the inhaler was normally given to him/her to self-administer, that he/she had never been assessed to self-administer the inhaler, and that he/she never rinsed the mouth after using it. The care plan contained no focus or intervention related to self-administration, and the EMR contained no self-administration assessment. For Resident 81, the record showed an order for PRN albuterol inhaler use, but no order for self-administration of the inhaler or eye drops. Observations showed Refresh Relieva eye drops, Refresh Mega-3 eye drops, and an albuterol inhaler at the bedside, including the inhaler not in a box or container. The resident stated that the eye drops had been given by the eye doctor, that both eye drops were being used twice daily, that the inhaler had been given on the resident's return from the hospital for use as needed, and that the resident had been taking the inhaler three to four times a day without telling staff. The resident also stated not knowing that staff needed to be informed whenever any medication was self-administered. The care plan had no focus or intervention related to self-administration, and the MAR showed no documentation related to the albuterol inhaler. Staff interviews confirmed that an assessment and order were needed for self-administration and that Resident 81 should have had orders for all medications, while the DON stated she was unaware the resident had eye drops at the bedside that were not currently ordered.
Respiratory Equipment Not Stored Properly
Penalty
Summary
The facility failed to store a BiPAP mask and a nasal cannula in a plastic bag for one resident who was admitted with COPD, acute and chronic respiratory failure with hypoxia, and acute and chronic respiratory failure with hypercapnia. The resident’s orders included BiPAP at night and oxygen at 2 liters per NC continuously, and the care plan addressed continuous oxygen therapy and BiPAP use, but did not address storage of the NC or BiPAP mask. The quarterly MDS indicated the resident was cognitively intact, and oxygen therapy and BiPAP therapy were not indicated on that assessment. During observations of the resident’s room, the BiPAP mask was seen laying on a pile of clothing and not stored in a plastic bag, and there was no plastic bag on the oxygen concentrator for NC storage. The NC was also observed wrapped around the handles of the resident’s wheelchair. Staff interviews stated that NCs and BiPAP masks were to be stored in dated plastic bags when not in use, that the NC should be replaced and placed in a plastic storage bag if found out of the bag, and that the BiPAP mask should be cleaned, dried, and placed in a plastic bag. Staff also stated the resident was noncompliant with storage of the respiratory items and that the DON and MDS Coordinator would be informed so the care plan could be updated.
Failure to Address Trauma-Related Needs in Care Plans
Penalty
Summary
The facility failed to identify, assess, and provide supportive interventions for two sampled residents with trauma-related needs. One resident had a diagnosis of PTSD, and another resident had a positive trauma/abuse/neglect screening with a history of suspected physical and sexual abuse. In both cases, the residents’ trauma-related findings were documented in screening tools and records, but the care plans did not address PTSD, trauma triggers, or interventions. For the resident with PTSD, the record showed repeated trauma/abuse/neglect screenings with yes responses indicating trauma-related symptomology, including disturbing memories, distress when reminded of past events, avoidance, feeling distant from others, and irritability or angry outbursts. The resident’s quarterly MDS documented PTSD and cognitive intactness. The care plan revision did not address PTSD, triggers, or interventions. During interview, the resident stated no staff had asked what made the PTSD worse or better and did not want to talk about the PTSD. For the resident with a positive trauma screening, the admission record showed diagnoses of suspected adult physical abuse and suspected adult sexual abuse. Multiple trauma/abuse/neglect screenings showed trauma-related symptomology with a score of six. The care plan noted prior trauma related to abuse from men in the resident’s life and recent possible physical abuse, but it did not address triggers or interventions. During interview, the resident reported a history of trauma, anxiety around unknown males, and a preference to stay in the room and avoid crowds. Staff interviews showed the CMT, RN, MDS Coordinator, and DON were unfamiliar with the residents’ triggers and interventions or did not know the trauma findings were not addressed in the care plans.
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.
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Illustrative
What surveyors actually found near you
We read the 235 citations issued within 25 miles in the last 12 months — including the 9 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Harrisonville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Crown Rehab And Healthcare Center | 0.7 mi | ★★★★★ | 0 | 0 |
| Golden Years Center For Rehab And Healthcare | 1.4 mi | ★★★★★ | 37 | 3 |
| Aspire Senior Living Pleasant Hill | 9.7 mi | ★★★★★ | 2 | 0 |
| Sunrise Nursing & Rehabilitation | 11.7 mi | ★★★★★ | 1 | 0 |
| Foxwood Springs Living Center | 13.7 mi | ★★★★★ | 1 | 0 |
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