Inspection Reports for
Hartville Care Center
649 WEST ROLLA ST, HARTVILLE, MO, 65667-8221
Back to Facility ProfileDeficiencies (last 5 years)
Deficiencies (over 5 years)
5.6 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
2% worse than Missouri average
Missouri average: 5.5 deficiencies/year
Deficiencies per year
16
12
8
4
0
Occupancy
Latest occupancy rate
67% occupied
Based on a June 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy rate 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
Plan of Correction
Census: 28
Deficiencies: 8
Date: Nov 3, 2023
Visit Reason
The inspection was conducted to assess compliance with food safety and environmental regulations at Hartville Care Center, focusing on food procurement, preparation, sanitation, and environmental conditions in the kitchen and facility.
Findings
The facility failed to meet food safety requirements related to cleaning and sanitizing the ice machine, proper use of hair restraints by food employees, and maintaining a sanitary environment including cleaning of fans and vents. Several deficiencies were noted regarding chemical testing, cleaning schedules, and maintenance of equipment.
Deficiencies (8)
F812 Food safety requirements were not met as the facility failed to properly clean and sanitize the ice machine, maintain dishwasher chemical levels, and enforce hair restraints for food employees.
F921 The facility failed to provide a safe, functional, sanitary, and comfortable environment by not ensuring fans and vents were cleaned and maintained, including missing vent covers on the ice machine.
A6019 Light fixtures, vent covers, and fans were not maintained clean and in good repair, contributing to unsanitary conditions.
A7003 Employees did not consistently use effective hair restraints to prevent contamination of food or food-contact surfaces.
A7015 Food was not adequately protected from contamination, including improper temperature controls and handling procedures.
A7067 Nonfood-contact surfaces of equipment were not cleaned as often as necessary to prevent accumulation of dust, dirt, and debris.
A7074 Food-contact surfaces were not sanitized according to regulatory requirements, including immersion times and chemical concentrations.
A7076 Chemical sanitization concentrations exceeded permitted maximums or were not properly measured and documented.
Report Facts
Facility census: 28
Dishwasher chemical test ppm: 145
Dishwasher chemical test ppm: 200
Plan of Correction completion date: Compliance to be achieved by 2023-12-18
Inspection Report
Life Safety
Census: 28
Capacity: 60
Deficiencies: 4
Date: Nov 3, 2023
Visit Reason
The inspection was a Life Safety Code survey conducted to assess compliance with fire safety regulations and egress door locking arrangements at Hartville Care Center.
Findings
The facility failed to meet the 2012 edition Life Safety Code requirements related to egress door locking arrangements and combustible decorations. Deficiencies included delayed egress doors not releasing properly and combustible decorative materials used in violation of fire safety standards.
Deficiencies (4)
K222: The facility failed to ensure one egress door with a 15 second delayed release locking mechanism released properly after activation, potentially affecting residents and staff. The facility lacked a policy for maintenance of egress doors.
K753: The facility failed to prohibit combustible decorations as required by NFPA 101, with decorative webbing obstructing egress paths and no documentation that materials met fire retardant standards.
A2009: The storage of unnecessary combustible materials was prohibited but found in violation, referencing K753.
A2037: Exit requirements for unobstructed exits and fire-rated separations were not met, referencing K222.
Report Facts
Facility capacity: 60
Resident census: 28
Delayed egress door release time: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Adam Worsham | Laboratory Director or Provider/Supplier Representative | Signed the inspection report and plan of correction |
| Administrator | Interviewed regarding egress door maintenance and combustible decorations | |
| Maintenance Director | Responsible for maintaining egress doors and involved in plan of correction |
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: 3
Date: May 13, 2021
Visit Reason
The inspection was conducted in response to allegations of abuse involving a resident at Hartville Care Center. The investigation focused on the facility's failure to report and properly investigate allegations of physical and sexual abuse.
Complaint Details
The complaint investigation was triggered by allegations of physical and sexual abuse involving Resident #5. The allegations included a male aide pulling the resident's hair and throwing the resident, threats of rape, and combative behaviors. Staff failed to report these allegations to the Department of Health and Senior Services (DHSS) and the State Survey Agency within required timeframes. The administrator was initially unaware of the allegations until the surveyor reported them. The facility census at the time was 28.
Findings
The facility failed to report allegations of abuse to the State Survey Agency within required timeframes and did not conduct full and timely investigations of the allegations. Multiple staff failed to report or document the abuse allegations, and the administrator was initially unaware of the incidents.
Deficiencies (3)
F609: The facility failed to report allegations of abuse to the State Survey Agency within two hours of staff awareness and did not report the results of investigations within five working days. The facility also failed to take appropriate corrective action after allegations of physical and sexual abuse involving Resident #5.
F610: The facility failed to thoroughly investigate allegations of abuse, prevent further potential abuse during investigations, and report investigation results to the appropriate officials within five working days.
A8023: The facility failed to develop and implement written policies prohibiting mistreatment, neglect, and abuse, and failed to require reporting of such incidents to the department for any resident or vulnerable person.
Report Facts
Facility census: 28
Deficiencies cited: 3
Inspection Report
Annual Inspection
Deficiencies: 0
Date: May 13, 2021
Visit Reason
The visit was conducted as an annual recertification survey and licensure inspection to assess compliance with life safety code and state licensure requirements.
Findings
No deficiencies were cited related to emergency preparedness or state licensure as a result of this annual inspection. The facility meets applicable provisions of the 2012 Life Safety Code.
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. |
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Jan 21, 2021
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control survey was conducted to assess compliance with relevant CMS and CDC guidelines.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness and with CMS and CDC recommended practices for COVID-19 infection control.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Dec 29, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control survey was conducted to assess compliance with CMS and CDC recommended practices related to COVID-19.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness and with CMS and CDC recommended practices for COVID-19 infection control.
Inspection Report
Routine
Deficiencies: 0
Date: Oct 29, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness survey and a COVID-19 Focused Infection Control Survey were conducted to assess compliance with relevant regulations and CDC recommended practices.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness and with CMS and CDC recommended practices for COVID-19 infection control.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Sep 17, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness survey and a COVID-19 Focused Infection Control Survey were conducted to assess compliance with CMS and CDC recommended practices related to COVID-19.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness and with CMS and CDC recommended practices for COVID-19 infection control.
Inspection Report
Routine
Deficiencies: 0
Date: Aug 5, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control survey was conducted to assess compliance with federal regulations and CDC recommended practices related to COVID-19.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness and with CMS and CDC recommended practices for COVID-19 infection control.
Inspection Report
Routine
Deficiencies: 0
Date: Jun 9, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control survey was conducted to assess compliance with CMS and CDC recommended practices related to COVID-19.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness and with CMS and CDC recommended infection control practices for COVID-19.
Inspection Report
Plan of Correction
Census: 29
Deficiencies: 2
Date: Feb 27, 2019
Visit Reason
The inspection was conducted to assess compliance with regulations regarding the use of psychotropic medications and nursing care standards at Hartville Care Center.
Findings
The facility failed to ensure a medication regimen free from unnecessary psychotropic drugs and did not adequately document indications for antipsychotic medication use. The resident sample showed issues with medication management and behavioral interventions.
Deficiencies (2)
F758: The facility failed to ensure a medication regimen free from unnecessary psychotropic medications and did not provide adequate indications for antipsychotic medication use for one resident in a sample of 14.
A4074: Each resident shall receive personal attention and nursing care consistent with current acceptable nursing practice. This regulation was not met as evidenced by the deficiency in F758.
Report Facts
Facility census: 29
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Natasha Wiley | Administrator | Signed the statement of deficiencies and plan of correction |
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Feb 27, 2019
Visit Reason
The inspection was conducted as an annual recertification survey to assess compliance with the Life Safety Code and state licensure requirements.
Findings
No emergency preparedness deficiencies or state licensure deficiencies were cited during this annual inspection. The facility met the applicable provisions of the 2012 edition of the Life Safety Code.
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