Inspection Reports for
Hartville Care Center
649 WEST ROLLA ST, HARTVILLE, MO, 65667-8221
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
3.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
33% better than Missouri average
Missouri average: 5.5 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
40 residents
Based on a June 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy over time
Inspection Report
Routine
Census: 40
Deficiencies: 5
Date: Jun 19, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory standards related to respiratory care, food safety, medical record documentation, facility environment, and pest control at Hartville Care Center.
Findings
The facility was found deficient in providing appropriate respiratory care, maintaining food safety standards, documenting resident injuries properly, maintaining a clean and functional environment, and controlling pests effectively. Specific issues included failure to date and change oxygen equipment, inadequate air gap for ice machine drainage, greasy stove burners, incomplete medical record documentation for a resident injury, peeling floor in the walk-in cooler, and presence of flies in resident rooms and kitchen.
Deficiencies (5)
Failure to provide respiratory care per standards including undated oxygen equipment and lack of care planning for oxygen use for two residents.
Failure to ensure food safety by not maintaining required air gap for ice machine drainage and greasy stove burners.
Failure to maintain complete and accurate medical records for a resident injury including lack of documentation of injury cause, monitoring, and notifications.
Failure to maintain a sanitary and functional environment due to peeling and uncleanable floor in the walk-in cooler.
Failure to maintain an effective pest control system with flies present in resident rooms and kitchen.
Report Facts
Facility census: 40
Oxygen tubing change order date: May 22, 2025
Nebulizer tubing change order date: Nov 11, 2023
Resident #22 admission date: Nov 11, 2023
Resident #10 admission date: Oct 3, 2024
Resident #36 admission date: Mar 29, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN G | Licensed Practical Nurse | Interviewed regarding oxygen tubing and nebulizer mask change procedures |
| CMT F | Certified Medication Technician | Interviewed regarding oxygen and nebulizer tubing change responsibilities |
| CMT H | Certified Medication Technician | Interviewed regarding oxygen tubing and nebulizer mask change and tubing storage |
| RN D | Registered Nurse | Interviewed regarding oxygen tubing change schedule and resident injury documentation |
| ADON | Assistant Director of Nursing | Interviewed regarding oxygen care planning and resident injury documentation |
| DON | Director of Nursing | Interviewed regarding oxygen equipment standards and resident injury documentation |
| Administrator | Interviewed regarding expectations for oxygen equipment care and resident injury documentation | |
| Dietary Staff A | Interviewed regarding ice machine air gap and fly presence in kitchen | |
| Dietary Staff B | Interviewed regarding ice machine air gap, stove cleaning, and fly presence in kitchen | |
| Dietary Manager | Interviewed regarding ice machine air gap, stove cleaning, and fly control | |
| Maintenance Director | Interviewed regarding ice machine air gap and walk-in cooler floor condition | |
| Maintenance Supervisor | Interviewed regarding walk-in cooler floor and pest control | |
| CNA C | Certified Nursing Assistant | Interviewed regarding resident injury reporting and fly presence |
| RN D | Registered Nurse | Interviewed regarding resident injury documentation and fly presence |
| CNA E | Certified Nursing Assistant | Interviewed regarding fly presence |
Inspection Report
Routine
Census: 28
Deficiencies: 4
Date: Nov 3, 2023
Visit Reason
The inspection was conducted to evaluate the facility's compliance with food safety, sanitation, and environmental standards in the kitchen and food service areas.
Findings
The facility failed to maintain proper sanitation of the ice machine, ensure dishwasher chemicals were tested at recommended levels, and enforce proper hair covering policies for kitchen staff. Additionally, the facility did not maintain cleanliness and repair of fans and vents in the refrigerator and ice machine areas.
Deficiencies (4)
Failed to keep the ice machine clean, with black spots inside and no documented cleaning in October 2023.
Dishwasher chemicals were not consistently tested at recommended levels; several days in October showed under 150 ppm or no testing.
Staff with facial hair did not wear proper hair coverings as required by food safety standards.
Fans in the walk-in refrigerator and vents on the ice machine were not cleaned properly; vent covers on the ice machine were missing or broken.
Report Facts
Dishwasher chemical testing days: 13
Dishwasher chemical non-testing days: 14
Facility census: 28
Employees mentioned
| Name | Title | Context |
|---|---|---|
| DA A | Dietary Aide | Interviewed regarding ice machine cleaning and dishwasher chemical testing |
| DA B | Dietary Aide | Interviewed regarding ice machine cleaning, dishwasher chemical testing, and hair covering policy |
| DA C | Dietary Aide | Interviewed regarding ice machine cleaning, dishwasher chemical testing, and hair covering policy |
| Dietary Manager | Interviewed regarding ice machine cleaning, dishwasher chemical testing, and hair covering policy | |
| Maintenance Manager | Interviewed regarding ice machine cleaning and vent maintenance | |
| Administrator | Interviewed regarding maintenance responsibilities and facility policies | |
| Registered Dietician | Interviewed regarding hair covering policy |
Inspection Report
Complaint Investigation
Census: 28
Deficiencies: 2
Date: May 13, 2021
Visit Reason
The inspection was conducted due to allegations of physical and sexual abuse made by Resident #5. The facility was investigated for failure to timely report and properly investigate these abuse allegations.
Complaint Details
The complaint involved Resident #5 who made allegations of physical and sexual abuse by staff. The facility failed to report these allegations to the Department of Health and Senior Services (DHSS) within the required two-hour timeframe and did not conduct a thorough investigation. The resident exhibited severe cognitive impairment and delusions. Staff and administration were unaware or did not act on the allegations until the survey. The allegations included a male aide pulling the resident's hair and throwing the resident, threats by an aide, and the resident stating staff were trying to rape him/her.
Findings
The facility failed to report allegations of abuse to the State Survey Agency within two hours as required and did not complete full and timely investigations of the abuse allegations. Resident #5 exhibited severe cognitive impairment and made multiple allegations of abuse, including physical and sexual abuse, which staff did not report or investigate properly. The administrator and Director of Nursing were unaware of the allegations until the investigation. Staff assumed the resident was delusional and did not report the allegations as abuse.
Deficiencies (2)
Failure to timely report allegations of abuse to the State Survey Agency within two hours of staff becoming aware.
Failure to complete full and timely investigations of allegations of abuse.
Report Facts
Facility census: 28
Date of survey completion: May 13, 2021
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN E | Registered Nurse | Documented resident behaviors and was involved in care during abuse allegations; did not report allegations to authorities. |
| RN F | Registered Nurse | Documented resident behaviors and allegations of abuse in nurse's notes. |
| CMT A | Certified Medication Technician | Reported resident's anxiety and abuse allegations to nurse RN E. |
| CNA B | Certified Nursing Assistant | Witnessed resident's refusal to go to bed and abuse allegations; reported incident to RN E. |
| CNA C | Certified Nursing Assistant | Witnessed resident's abuse allegations and reported incident to RN E. |
| CNA D | Certified Nursing Assistant | Involved in resident care during abuse allegations; reported incident to RN E. |
| Director of Nursing (DON) | Director of Nursing | Interviewed during investigation; acknowledged failure to investigate and report allegations. |
| Administrator | Facility Administrator | Interviewed during investigation; was unaware of abuse allegations until survey and stated expectations for reporting and investigation. |
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