Inspection Reports for Meadow View Health & Rehabilitation
2203 E Mechanic St, Harrisonville, MO 64701, United States, MO, 64701
Back to Facility ProfileDeficiencies (last 5 years)
Deficiencies (over 5 years)
10.4 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
89% worse than Missouri average
Missouri average: 5.5 deficiencies/yearDeficiencies per year
28
21
14
7
0
Census
Latest occupancy rate
82 residents
Based on a May 2025 inspection.
Census over time
Inspection Report
Complaint Investigation
Census: 82
Deficiencies: 3
May 29, 2025
Visit Reason
The inspection was conducted due to a complaint regarding the condition and cleanliness of resident shower rooms, specifically concerns about mold buildup, missing tiles, and maintenance issues.
Findings
The facility failed to maintain shower rooms in a clean and safe condition, with observations of black mold-like grime, missing tiles, exposed building studs, and unclean resident toilets. Staff interviews revealed lack of awareness and inadequate cleaning or maintenance protocols for these issues.
Complaint Details
Complaint # MO 00253529 regarding mold buildup, missing tiles, and cleanliness issues in resident shower rooms.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Resident shower rooms were not kept clean, with build-up of black mold-like grime on shower walls and floors. | Level of Harm - Minimal harm or potential for actual harm |
| Shower rooms showed missing baseboard shower tiles and missing tiles on memory care floor and in the shower itself. | Level of Harm - Minimal harm or potential for actual harm |
| Resident toilet was not clean, with old brown substance splatter inside the bowl. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Facility census: 82
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Shower Aide B | Interviewed regarding cleaning and disinfecting showers after resident use | |
| Certified Medication Technician B | Interviewed regarding awareness of mold in shower rooms | |
| Housekeeper B | Interviewed regarding awareness and cleaning responsibilities for mold buildup | |
| Registered Nurse A | Registered Nurse | Interviewed regarding awareness of mold and odor in shower rooms |
| Maintenance Director | Maintenance Director | Interviewed regarding maintenance responsibilities and awareness of missing tiles |
| Administrator | Administrator | Interviewed regarding expectations for staff notification and maintenance of shower rooms |
Inspection Report
Complaint Investigation
Census: 91
Deficiencies: 1
Sep 9, 2024
Visit Reason
The inspection was conducted due to a complaint regarding the facility's failure to provide restorative therapy services to a resident with limited range of motion (ROM).
Findings
The facility failed to ensure that Resident #1, who had limited ROM and was supposed to receive restorative nursing services three times a week, actually received these services. The resident had zero days of restorative nursing in the seven days prior to the survey and had only received ten minutes of restorative therapy over a several-week period. The facility had been without a Restorative Aide since July 10, 2024, which contributed to the lack of therapy services.
Complaint Details
The complaint investigation found that the resident had not received restorative therapy for three months due to staffing issues, specifically the absence of a Restorative Aide since July 10, 2024. Interviews with staff confirmed uncertainty about therapy services and responsibility during the absence of the Restorative Aide.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to provide appropriate restorative therapy services to a resident with limited range of motion. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents present: 91
Restorative therapy sessions: 0
Restorative therapy minutes: 10
Restorative Aide absence duration: 61
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Certified Medication Technician (CMT) A | Interviewed regarding therapy services and training | |
| Licensed Practical Nurse (LPN) A | Interviewed regarding resident's therapy and facility staffing | |
| Director of Nursing (DON) | Interviewed regarding restorative therapy orders and facility staffing | |
| Administrator | Interviewed regarding restorative therapy re-evaluation and staffing | |
| Certified Occupational Therapist Assistant (COTA) A | Interviewed regarding restorative therapy orders and facility staffing | |
| Assistant Director of Nursing (ADON) | Interviewed regarding restorative therapy oversight and staffing |
Inspection Report
Routine
Census: 88
Deficiencies: 2
May 23, 2024
Visit Reason
The inspection was conducted to evaluate compliance with regulations related to resident care, specifically focusing on activities of daily living such as bathing, grooming, and toileting, and to assess staffing adequacy.
Findings
The facility failed to ensure residents received scheduled showers and baths, with documentation gaps and inconsistent bathing care for multiple residents. Staffing shortages, especially on the [NAME] Side and during weekends, contributed to inadequate care delivery and unmet resident needs.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to provide scheduled showers and baths for residents, with missing documentation and lack of follow-up on refusals. | Level of Harm - Minimal harm or potential for actual harm |
| Insufficient nursing staff to meet resident care needs, resulting in delayed or missed assistance with activities of daily living including bathing, dressing, and toileting. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Facility census: 88
Scheduled showers/baths vs received: 4
Scheduled showers/baths vs received: 3
Scheduled showers/baths vs received: 1
Scheduled showers/baths vs received: 5
Scheduled showers/baths vs received: 3
Scheduled showers/baths vs received: 0
Scheduled showers/baths vs received: 1
Scheduled showers/baths vs received: 2
Residents requiring assistance: 70
Residents requiring assistance with eating: 60
Staffing levels: 2
Residents on SCU: 17
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| CMT A | Certified Medication Technician | Reported resident incontinence and shower refusals; sole staff on SCU during part of day shift |
| CMT C | Certified Medication Technician | Reported shower schedule and documentation issues |
| CNA D | Certified Nurse Assistant | Described shower scheduling and documentation practices |
| CNA B | Certified Nurse Assistant | Described shower documentation and resident refusals |
| RN A | Registered Nurse | Described shower/bathing expectations and staffing |
| ADON | Assistant Director of Nursing | Described performance improvement plan for bathing and staffing responsibilities |
| Marketing Coordinator | Marketing Director/Coordinator | Assisted on SCU during staffing shortage |
| Administrator | Facility Administrator | Responsible for addressing staffing issues and PBJ data |
Inspection Report
Routine
Census: 88
Deficiencies: 9
May 21, 2024
Visit Reason
The inspection was conducted to assess compliance with health and safety regulations, including environmental cleanliness, resident care, feeding, staffing, food preparation, and ventilation.
Findings
The facility was found deficient in maintaining a clean environment, ensuring adequate bathing and showering of residents, proper pressure ulcer care, accurate documentation and management of feeding tube use, sufficient staffing levels, food preparation and serving at appropriate temperatures, and proper ventilation in resident restrooms.
Deficiencies (9)
| Description |
|---|
| Failed to maintain floors, fans, and ceiling vents free from heavy dust and debris in multiple resident rooms. |
| Failed to ensure residents received scheduled showers and baths, with documentation and staffing issues contributing to inadequate bathing care. |
| Failed to obtain physician order for low air loss mattress settings for a resident with a Stage II pressure ulcer. |
| Failed to ensure accurate documentation of refusal of enteral feeding via feeding tube and physician order for total caloric intake for a resident at risk for weight loss. |
| Failed to ensure sufficient nursing staff to meet resident needs and provide timely ADL assistance, with inadequate weekend staffing and insufficient staff on certain shifts. |
| Failed to cook and puree broccoli properly, maintain food temperatures on room trays, and ensure palatable food for residents. |
| Failed to puree turkey into a smooth texture for residents on pureed diets. |
| Failed to maintain kitchen and food storage areas clean and in good repair, including dust and grime buildup, damaged gaskets, inadequate trash containers, and improper milk storage temperature. |
| Failed to ensure negative airflow in restrooms of multiple resident rooms. |
Report Facts
Facility census: 88
Residents affected by dust and debris: 30
Residents affected by feeding tube documentation issues: 1
Residents affected by pressure ulcer mattress order issue: 1
Residents affected by staffing deficiencies: 2
Residents affected by food temperature and preparation issues: 13
Residents affected by ventilation issues: 20
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| CMT A | Certified Medication Technician | Mentioned in relation to staffing and feeding assistance |
| Housekeeping Supervisor | Mentioned regarding staffing and cleaning issues | |
| Maintenance Director | Mentioned regarding environmental and ventilation issues | |
| Dietary Director | Mentioned regarding food preparation and kitchen deficiencies | |
| Assistant Director of Nursing | Mentioned regarding staffing and care issues | |
| RN A | Registered Nurse | Mentioned regarding feeding tube and care documentation |
| LPN B | Licensed Practical Nurse | Mentioned regarding pressure ulcer mattress settings |
| CNA A | Certified Nursing Assistant | Mentioned regarding staffing and resident care |
| Marketing Coordinator | Assisted with resident care during staffing shortage |
Inspection Report
Complaint Investigation
Census: 93
Deficiencies: 1
Aug 14, 2023
Visit Reason
The inspection was conducted following a complaint regarding disrespectful and rude behavior by a Certified Nursing Assistant (CNA A) towards a resident (Resident #2). The investigation focused on the resident's dignity and respect rights.
Findings
The facility failed to promote and enhance the resident's feelings of self-worth and dignity when CNA A made disrespectful and rude remarks to Resident #2. The incident was documented by a recording made by the resident. The facility took corrective actions including staff education and updating care plans.
Complaint Details
The complaint was substantiated based on a recording made by the resident, which captured CNA A making rude and disrespectful comments. The resident was cognitively intact and required assistance with personal care. Multiple staff were reluctant to provide witness statements. The resident was discharged to another facility shortly after the incident.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Census: 93
Resident BIMS score: 15
Resident assistance requirements: 1
Resident assistance requirements: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| CNA A | Certified Nursing Assistant | Named in disrespectful and rude behavior towards Resident #2 |
| Director of Nursing | Director of Nursing | Interviewed regarding the incident and CNA A's denial of wrongdoing |
| Administrator | Administrator | Interviewed regarding the incident and resident discharge |
| Social Worker | Social Worker | Received complaint from resident and confirmed recording of incident |
Inspection Report
Complaint Investigation
Census: 86
Deficiencies: 2
Mar 14, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding the misappropriation of property and exploitation of Resident #500 by a Hospitality Aide (HA) employed at the facility.
Findings
The facility failed to protect Resident #500 from exploitation and misappropriation of property by HA A, who manipulated the resident emotionally, took money, and obtained the resident's truck under false pretenses. The resident suffered emotional harm and attempted self-harm. Additionally, the facility failed to obtain physician orders and properly document care related to a Foley catheter and colostomy for Resident #501.
Complaint Details
The complaint involved allegations that HA A exploited Resident #500 by befriending the resident, emotionally manipulating him/her, taking money, and obtaining the resident's truck. The resident was emotionally harmed and attempted self-harm. The investigation confirmed the allegations and found the staff member had a relationship with the resident and misappropriated property.
Severity Breakdown
Level of Harm - Actual harm: 1
Level of Harm - Minimal harm or potential for actual harm: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to protect Resident #500 from wrongful use of belongings or money by a staff member who exploited the resident for personal gain. | Level of Harm - Actual harm |
| Failed to obtain physician's order and document care for Foley catheter and colostomy for Resident #501. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Facility census: 86
Residents affected: 1
Residents affected: 1
Money taken: 700
Rings cost: 50
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| HA A | Hospitality Aide | Named in exploitation and misappropriation of resident property finding |
| CNA B | Certified Nursing Assistant | Witnessed resident with rings and emotional distress |
| CMT B | Certified Medication Technician | Observed resident's emotional state post-exploitation |
| LPN B | Licensed Practical Nurse | Observed resident's change in behavior after exploitation |
| Social Services Designee | Provided statement on resident's emotional state and police involvement | |
| Program Director | Hospital Behavioral Health Facility Program Director | Reviewed text messages and confirmed exploitation |
| CMT A | Certified Medication Technician | Reported resident's loss of truck and emotional distress |
| ADON | Assistant Director of Nursing | Informed about resident's situation and police involvement |
| DON | Director of Nursing | Stated policy on staff relationships with residents and knowledge of incident |
| CNA C | Certified Nursing Assistant | Described routine catheter care practices |
| CNA A | Certified Nursing Assistant | Described routine catheter and colostomy care practices |
| LPN D | Licensed Practical Nurse | Reported lack of physician orders for Foley catheter and colostomy care |
| RN A | Registered Nurse | Described expectations for physician orders and documentation |
Inspection Report
Complaint Investigation
Census: 88
Deficiencies: 2
Feb 8, 2023
Visit Reason
The inspection was conducted due to a complaint regarding the facility's failure to provide an appropriate discharge for one sampled resident (Resident #81) who was discharged to the hospital and refused re-admission despite an appeal process.
Findings
The facility failed to provide an appropriate discharge notice with required information and did not notify the resident, guardian, or ombudsman properly. The resident was discharged to the hospital due to combativeness and aggression, but the facility refused to readmit the resident despite the hospital's clearance and appeal dismissal. The emergency discharge notice lacked required details and was not properly communicated.
Complaint Details
The complaint involved Resident #81 who was discharged to the hospital due to combativeness and aggression. The hospital cleared the resident to return, but the facility refused re-admission. The resident and Public Administrator appealed the discharge. The appeal was dismissed due to improper discharge notice. The facility did not notify the resident, guardian, or ombudsman properly and did not assist in finding alternative placement.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to provide an appropriate discharge for one sampled resident discharged to the hospital and refused re-admission despite appeal. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide timely notification to the resident, resident representative, and ombudsman before transfer or discharge, including appeal rights. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents affected: 1
Facility census: 88
Dates: 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Social Service Director (SSD) | Provided statements regarding the resident's discharge and communication with hospital and facility. | |
| Regional Director | Confirmed facility decision not to readmit resident due to combativeness and aggressive behaviors. | |
| Facility Administrator | Informed SSD and Ombudsman of facility's refusal to readmit resident and incomplete discharge notice. | |
| Ombudsman | Reported attempts to contact facility and issues with discharge notice and resident readmission. | |
| Charge Nurse or Administrator | Completed emergency discharge notice and faxed to hospital but omitted required information. |
Inspection Report
Routine
Census: 95
Deficiencies: 25
Sep 20, 2022
Visit Reason
The inspection was conducted based on a routine survey of Meadow View Health & Rehabilitation to assess compliance with regulatory requirements.
Findings
The facility was found deficient in multiple areas including resident dignity and self-worth, reasonable accommodation of resident needs, advanced directives documentation, abuse prevention and investigation, staffing adequacy, care planning, wound care, dialysis care, medication management, and provision of activities. Specific issues included residents being left in hospital gowns, lack of alternate meal choices at breakfast, delayed treatment of wounds and infections, inadequate behavioral health services, failure to report and investigate abuse properly, insufficient staffing to meet resident needs, and medication errors.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 22
Level of Harm - Actual harm: 5
Level of Harm - Immediate jeopardy to resident health or safety: 1
Deficiencies (25)
| Description | Severity |
|---|---|
| Failure to promote dignity and self-worth for residents by leaving them in hospital gowns and not assisting with dressing. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to reasonably accommodate resident needs and preferences including serving meals on Styrofoam and lack of access to beverages and snacks. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to promote resident self-determination by not providing access to food and beverages when hungry and not assisting with getting out of bed and dressing. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to ensure resident's advanced directives wishes were communicated and documented accurately. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to protect residents from abuse; resident was struck by another resident causing injury and the incident was not properly reported or investigated. | Level of Harm - Actual harm |
| Failure to conduct employee background checks prior to hire to ensure no disqualified individuals were employed. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to timely report suspected abuse to the State as required. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to thoroughly investigate allegations of resident abuse by not interviewing all witnesses or reviewing pertinent information. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to notify resident and representative in writing of discharge including reason and appeal rights. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to follow through with PASARR recommendations and integrate them into the care plan. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide ongoing resident-centered activities that meet individual needs and preferences. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to identify, assess, monitor and treat wounds and skin issues in a timely manner, and failure to ensure physician orders for pressure injury prevention were followed. | Level of Harm - Actual harm |
| Failure to ensure timely physician notification and treatment for resident with C. Diff infection. | Level of Harm - Actual harm |
| Failure to ensure safe smoking assessments were completed for residents who smoke. | Level of Harm - Immediate jeopardy to resident health or safety |
| Failure to provide adequate staffing to meet resident needs including assistance with dressing, transfers, and dining. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to respond appropriately to alleged violations of abuse by conducting thorough investigations. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide timely notification of abuse to the State. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide complete care plans within required timeframes and to include resident and representative participation. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide safe, appropriate pain management including clarifying acetaminophen dosing limits and continuing hospital discharge medications. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide safe, appropriate dialysis care including ongoing assessment and communication with dialysis center. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide adequate activities program that meets resident needs and preferences. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide appropriate treatment and care for residents with mental disorders including behavioral assessments, monitoring, and non-pharmacological interventions. | Level of Harm - Actual harm |
| Failure to ensure medication error rate was less than 5% with errors observed in insulin administration. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to ensure IV medications were administered as ordered and missed doses were properly documented and reported. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide residents with sufficient alternate food choices at breakfast. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Medication opportunities observed: 25
Facility census: 95
Missed doses of Vancomycin: 2
Days delay in antibiotic treatment: 7
Residents sampled: 19
Employees sampled: 10
Inspection Report
Annual Inspection
Census: 82
Deficiencies: 7
Oct 11, 2019
Visit Reason
The inspection was conducted as part of the annual survey of Meadow View Health & Rehabilitation to assess compliance with Medicare and Medicaid regulations, including review of resident care, medication management, employee background checks, and notification procedures.
Findings
The facility was found deficient in multiple areas including failure to provide correct Medicare Non-Coverage notices, incomplete employee background checks prior to hiring, failure to notify residents and representatives timely of hospital transfers, failure to provide baseline care plans to residents and their representatives, improper medication administration practices including pre-pouring medications, discrepancies in controlled medication records, and improper medication storage and labeling.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 7
Deficiencies (7)
| Description | Severity |
|---|---|
| Failed to provide the correct Notice of Medicare Non-Coverage form for three sampled residents and failed to verify timely delivery of notices for one resident. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to request a Criminal Background Check prior to hiring one employee and failed to check the CNA Registry prior to hiring another employee. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to notify residents and their representatives in writing of hospital transfers and failed to notify the Ombudsman for two residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide baseline care plans or summaries to residents and their representatives within 48 hours of admission for four residents. | Level of Harm - Minimal harm or potential for actual harm |
| Pre-poured medications during medication pass for two residents, contrary to accepted clinical practice standards. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure medication administration records matched controlled medication records for one resident. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure medications were labeled with opened dates and stored properly; found batteries and a resident's gait belt stored in medication drawers. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents present: 82
Employees hired since last annual survey: 46
Controlled medication administrations discrepancy: 5
Controlled medication administrations discrepancy: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Employee C | Hired without timely Criminal Background Check | |
| Employee D | Hired without prior CNA Registry check | |
| Human Resources Manager | Human Resources Manager | Interviewed regarding employee background checks |
| Director of Nursing | Director of Nursing | Interviewed regarding notification procedures, medication administration, and employee background checks |
| Corporate Nurse | Corporate Nurse | Interviewed regarding notification procedures and employee background checks |
| Social Service Director | Social Service Director | Interviewed regarding hospital transfer notifications and Ombudsman notifications |
| Minimum Data Set Coordinator | MDS Coordinator | Interviewed regarding baseline care plan provision |
| Licensed Practical Nurse A | Licensed Practical Nurse | Interviewed regarding medication administration and baseline care plan |
| Licensed Practical Nurse B | Licensed Practical Nurse | Observed pre-pouring medications and interviewed about medication administration practices |
| Certified Medication Technician A | Certified Medication Technician | Interviewed regarding medication administration and medication cart observations |
| Certified Medication Technician B | Certified Medication Technician | Observed administering medication and interviewed about medication labeling |
| Registered Nurse A | Registered Nurse | Interviewed regarding medication administration and medication cart observations |
| Assistant Director of Nursing | Assistant Director of Nursing | Interviewed regarding controlled medication records |
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