Inspection Reports for
Meadow View Health & Rehabilitation

Complaint # MO 00253529 regarding mold buildup, missing tiles, and cleanliness issues in resident shower rooms.

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.

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.

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.

The facility failed to ensure that a sampled resident with limited range of motion received restorative therapy services to prevent further decline. Interviews and record reviews revealed the resident had not received restorative therapy for several months due to staffing and possible insurance issues.

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.

The facility was found to have multiple deficiencies including failure to maintain a safe, clean, and homelike environment, inadequate ADL care for dependent residents, pressure ulcer prevention and treatment issues, insufficient nursing staff, and food safety violations. The facility census was 88 residents during the survey.

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.

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.

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.

The complaint was substantiated as the CNA was found to have been rude and disrespectful to the resident. The resident recorded the interaction, and statements from the Director of Nursing and other witnesses supported the finding. The resident was discharged and relocated to another facility after the incident.

The facility failed to promote and enhance the dignity and respect of a sampled resident, as evidenced by a CNA's rude and disrespectful behavior. The resident recorded the interaction, and multiple interviews confirmed the incident as a dignity issue.

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.

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.

The complaint investigation substantiated that a Hospitality Aide exploited Resident #500 by emotional manipulation, taking money, and misappropriating property. The investigation included interviews, record reviews, and observations confirming the abuse and neglect.

The facility failed to protect Resident #500 from misappropriation and exploitation by a Hospitality Aide (HA) who took advantage of the resident for personal gain. Additionally, the facility failed to meet professional standards in nursing care for Resident #501 related to Foley catheter and colostomy care.

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.

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.

The complaint investigation focused on Resident #81's discharge to the hospital and the facility's refusal to readmit the resident despite an appeal. The discharge notice was incomplete and did not meet regulatory requirements. The resident's representative and Ombudsman were involved, and the discharge was found to be improper.

The facility failed to provide an appropriate discharge for Resident #81, discharging the resident to the hospital and refusing to allow re-admission despite an appeal. The facility also failed to provide proper discharge notices and documentation as required by regulations.

The facility was found not in compliance with emergency preparedness training requirements and life safety code provisions including emergency lighting, exit signage, fire door maintenance, sprinkler system inspections, and electrical system testing. Deficiencies were identified that could affect resident safety in emergency situations.

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.

The complaint investigation substantiated that the facility denied compassionate care visits to three residents and did not have a policy addressing visitation rights during the COVID-19 pandemic. The facility's COVID-19 policy restricted hospice chaplains and social workers from visitation, and family members were denied visitation despite emotional distress and end-of-life circumstances.

The facility failed to allow compassionate care visits to three sampled residents and did not have a policy in place for such visits. The facility's COVID-19 visitation policy restricted hospice chaplains and social workers from visitation rights, causing emotional distress to residents and families.

The facility failed to maintain adequate window stops to prevent resident elopement, posing a safety risk to residents on the Memory Care unit. The facility census was 78 residents at the time of inspection. The plan of correction includes securing windows and re-educating staff on elopement policies.

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.

The facility was found deficient in multiple areas including failure to provide correct Medicare Non-Coverage notices, failure to conduct timely criminal background checks for employees, inadequate notice requirements before resident transfers or discharges, failure to develop and provide baseline care plans, medication administration errors, improper medication storage and labeling, and failure to properly screen employees for communicable diseases and tuberculosis.

The facility failed to meet applicable Life Safety Code provisions related to cooking facilities, fire alarm system testing and maintenance, and fire door assemblies. Deficiencies included lack of proper connection of the kitchen range hood suppression system to the fire alarm system, incomplete fire alarm inspection documentation, and missing functional and visual assessments of fire resistive corridor doors.

The facility failed to ensure required physician visits were conducted timely and did not provide necessary mental health treatment and services consistent with professional standards. Deficiencies were noted in physician visit documentation, treatment of residents with mental/psychosocial concerns, and behavioral management.

The complaint involved an allegation of rape by a janitor against a resident with dementia and schizophrenia. The allegation was not reported timely to the Director of Nursing or Administrator, and the investigation was incomplete at the time of the survey. Staff interviews revealed confusion and failure to follow reporting protocols. The complaint was substantiated based on the findings.

The facility failed to report an allegation of rape involving a resident to the Director of Nursing and initiate an investigation in a timely manner. The investigation was incomplete at the time of the survey, and staff did not follow proper reporting procedures for suspected abuse.

Complaint MO 00151187 was investigated. The complaint involved failure of the facility's communication system during a landline outage and failure to notify appropriate supervisory staff. The complaint was substantiated as the facility failed to maintain adequate communication and notification procedures.

The facility failed to maintain an effective emergency communication system during a landline outage, lacked an alternate communication plan beyond landline phones and personal mobile phones, and did not notify the Director of Nursing or Administrator promptly about the communication system failure. The facility census was 74 residents at the time.

The facility was found to have multiple deficiencies including failure to provide adequate notice before transfer or discharge, incomplete pre-admission screening for mental illness, inadequate comprehensive care plans, improper medication storage and monitoring, insufficient infection control practices, and food safety violations. The facility census was 66 residents during the survey.

The facility was found to have multiple deficiencies related to fire safety, including failure to maintain fire resistance ratings, means of egress obstructions, fire alarm system testing and maintenance, sprinkler system inspections, fire drills, and emergency preparedness planning. Several deficiencies potentially affected residents, staff, and visitors across multiple smoke zones.