Original Inspection report

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265362

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

MEADOW VIEW OF HARRISONVILLE HEALTH & REHAB

STREET ADDRESS, CITY, STATE, ZIP

2203 EAST MECHANIC STREET
HARRISONVILLE, MO 64701

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0623

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Provide timely notification to the resident, and if applicable to the resident
representative and ombudsman, before transfer or discharge, including appeal rights.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to ensure notifications were
given to the resident and/or responsible party before discharging the resident to the
hospital for two sampled residents (Resident #47 and #4 ) out of 21 sampled residents. The
facility census was 66 residents.
1. Record review of Resident #47’s Face Sheet showed the resident was admitted to the
facility on [DATE] with [DIAGNOSES REDACTED]. (a progressive disease that destroys memory
and other important mental functions) and diabetes.
Record review of the resident’s significant change Minimum Data Set (MDS-a federally
mandated assessment tool to be completed by facility staff for care planning) dated
7/27/18, showed he/she::
-Had long and short-term memory loss with delusions and
-Needed extensive assistance with bed mobility, transfers, dressing, bathing, grooming and
toileting, and mobilized in a wheelchair.
Record review of the resident’s Nurses Notes showed on 8/15/18, he/she was discharged to
the hospital due to abdominal pain.
Record review of the resident’s MDS records showed he/she was discharged on [DATE] with
return anticipated. There was a re-entry MDS dated [DATE] showing that the resident was
readmitted to the facility from the hospital.
Record review of the resident’s medical record on 9/27/18 showed there was no
documentation that showed a discharge letter was given to the resident and/or the
resident’s responsible party at the time of discharge on 8/15/18.
2. Record review of Resident #4’s Face Sheet showed he/she was admitted to the facility on
[DATE], with [DIAGNOSES REDACTED].
Record review of the resident’s quarterly MDS dated [DATE], showed he/she:
-Was alert and oriented with little confusion;
-Needed total assistance with bed mobility, transfers, dressing, bathing, toileting and
mobilized in a wheelchair and
-Had upper and lower extremity limitations.
Record review of the resident’s Nurses Notes showed he/she was sent to the hospital and
returned on 7/3/18.
Record review of the resident’s MDS records showed he/she was discharged on [DATE], return
anticipated. An MDS dated [DATE], showed the resident re-entered the facility from the
hospital.
Record review of the resident’s medical record on 9/27/18 showed there was no
documentation that showed a discharge letter was given to the resident and/or the
resident’s responsible party at the time of discharge on 6/23/18.
3. During an interview on 10/1/18 at 11:15 A.M., that Social Service Director said that
nursing staff was responsible for completing the bed hold notification forms upon
discharge of the resident but they found that they were not being completed consistently.
He/she received training in (MONTH) to complete them and now he/she is responsible for
completing them and has been keeping track of all of the transfers holds and sending the
Ombudsman the monthly transfers.
During an interview on 10/03/18 at 2:14 P.M., the Director of Nursing (DON) said:
-When a resident has to go out (to the hospital) they are supposed to call him/her and
notify him/her and he/she will ask them if they have notified the resident and responsible
party of the transfer/discharge notification;

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265362

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

MEADOW VIEW OF HARRISONVILLE HEALTH & REHAB

STREET ADDRESS, CITY, STATE, ZIP

2203 EAST MECHANIC STREET
HARRISONVILLE, MO 64701

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0623

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 1)
-Nursing staff was in-serviced on the bed hold process during the summer of (YEAR) and
-The nursing staff were given education on the transfer forms.

F 0645

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

PASARR screening for Mental disorders or Intellectual Disabilities

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to ensure the level II screening
of the Pre-Admission Screening for Mental Illness/Mental [MEDICAL CONDITION] or Related
Condition (PASARR) was completed/obtained upon admission for one sampled resident and one
supplemental resident (Resident #25 and #17) out of 21 sampled residents. The facility
census was 66 residents.
1. Record review of Resident #25’s Face Sheet showed he/she was admitted to the facility
on [DATE], with [DIAGNOSES REDACTED].
Record review of the resident’s Level I PASARR screening dated 1/24/12, showed under the
level one screening criteria for serious mental illness, the resident:
-Had serious problems in level of functioning in the last 6 months and
-A Level II screening was indicated due to the resident having had serious problems
functioning within the prior six months.
Record review of the resident’s Minimum Data Set (MDS-a federally mandated assessment tool
to be completed by facility staff for care planning) dated 7/20/18, showed he/she:
-Had confusion, disorganized thought and short-term memory loss;
-Needed supervision with bed mobility, transfers, locomotion, eating, dressing, bathing
and toileting and
-Used a wheelchair for mobility.
Record review of the resident’s Social Service Notes showed he/she had a [DIAGNOSES
REDACTED]. His/her behavior record showed anger outbursts and agitation as monitored
behaviors.
Record review of the resident’s Behavior Monitoring record dated (MONTH) (YEAR), (MONTH)
(YEAR) and (MONTH) (YEAR), showed the resident’s targeted behaviors were agitation and
angry outbursts. The behavior records showed the resident did not have any exhibited
behaviors.
Record review of the resident’s Medical Record showed there was no PASARR Level II
screening documentation in the resident’s medical record.
2. Record review of Resident #17’s Face Sheet showed he/she was admitted to the facility
on [DATE], with [DIAGNOSES REDACTED].
Record review of the resident’s admission MDS dated [DATE], showed he/she:
-Had inattention and disorganized thought;
-Had delusional behaviors and
-Needed extensive assistance with bathing, dressing, toileting, bed mobility, transferring
and grooming.
Record review of the resident’s PASARR Level I screening dated 3/4/15, showed he/she:
-Showed signs/symptoms of major mental disorder-paranoid, flat affect and
hopelessness/helplessness;
-Had been diagnosed with [REDACTED].
-Had serious problems in level of functioning in the last 6 months and
-A Level II screening was indicated due to the resident having had serious problems
functioning within the prior six months.

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265362

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

MEADOW VIEW OF HARRISONVILLE HEALTH & REHAB

STREET ADDRESS, CITY, STATE, ZIP

2203 EAST MECHANIC STREET
HARRISONVILLE, MO 64701

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0645

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 2)
Record review of the resident’s Medical Record showed there was no PASARR Level II
screening in the resident’s medical record.
3. During an interview on 10/1/18 at 1:40 P.M., the Human Resources Manager said:
-The former Social Service Director used to ensure that the PASSAR level I and II
screenings were completed and in the resident’s medical record;
-Since he/she has taken on the role, he/she was not aware that they were supposed to check
the Level I screening to see if a Level II was indicated and follow up on that, so the
screening on the residents were not completed and
-Now that he/she is aware, he/she will make sure to check and follow up on any level II
screenings that are required or indicated.

F 0657

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Develop the complete care plan within 7 days of the comprehensive assessment; and
prepared, reviewed, and revised by a team of health professionals.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to revise the comprehensive care
plan after a significant change assessment was completed showing the resident’s prognosis
change for one sampled resident (Resident #58) out of 21 sampled residents. The facility
census was 66 residents.
1. Record review of Resident #58’s face sheet showed he/she was admitted to the facility
on [DATE].
Record review of the resident’s Significant Change Minimum Data Set (MDS – a federally
mandated assessment tool required to be completed by the facility staff for care
planning), dated 8/21/18 showed the resident:
-Was cognitively impaired;
-Needed extensive assistance with bed mobility, dressing, and eating;
-Needed total assistance with transfers, locomotion, personal hygiene and bathing;
-Was always incontinent of bowel and bladder;
-Was impaired on both sides of his/her lower extremity and
-Had a condition or chronic disease that may result in a life expectancy of less than six
months.
Record review of the resident’s Telephone Order Sheet (TOS) dated 8/10/18 showed an order
for [REDACTED].
Record review of the resident’s second TOS dated 8/10/18, showed at 1:15 P.M an order was
received for the resident to be admitted to hospice services with a [DIAGNOSES REDACTED].
Record review of the resident’s Outside Hospital Do Not Resuscitate (DNR) order showed the
document was signed by the resident’s guardian and physician on 8/11/18.
Record review of the resident’s current care plan showed:
-It was most recently reviewed on 10/31/17;
-It was not updated/revised after the resident’s significant change MDS dated [DATE] was
completed and
-It did not show collaboration with the hospice agency on a coordinated plan of care.
During an interview on 10/3/18 at 11:41 A.M, Licensed Practical Nurse (LPN) C said:
-When a resident has a significant change, the resident’s condition is discussed during
morning meetings;
-The Social Worker and the MDS Coordinator attend the meetings;
-The changes to are looked at and further discussed by the MDS Coordinator and Social

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265362

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

MEADOW VIEW OF HARRISONVILLE HEALTH & REHAB

STREET ADDRESS, CITY, STATE, ZIP

2203 EAST MECHANIC STREET
HARRISONVILLE, MO 64701

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0657

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 3)
Worker, along with discussing what needs to be done related to care plans and
-Everyone is responsible for making sure the care plans are updated.
During an interview on 10/03/18 at 11:48 A.M., the MDS Coordinator said the resident’s
care plan should be reviewed and revised after a Significant Change MDS is completed; and
he/she would check the computer to see if the resident’s care plan was updated.
During an interview on 10/03/18 at 12:24 P.M., the MDS Coordinator said after checking the
computer he/she did not find a revised or updated care plan.
During an interview on 10/03/18 at 12:52 P.M., the Director of Nursing (DON) said:
-Nursing staff puts orders onto the care plan;
-There should have been a revision to the resident’s care plan after the resident
significant change and
-Training with MDS workers and CNAs for MDS coding and care planning is still taking place
all across the board.

F 0658

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Ensure services provided by the nursing facility meet professional standards of
quality.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review the facility failed to obtain a physician’s order for
an indwelling urinary catheter that included the size, type, and how often to change the
catheter for one sampled resident (Resident #36); failed to obtain a physician’s order for
the care of a [MEDICAL CONDITION] site to be done by the resident, failed to have
documentation of the assessment and monitoring of a [MEDICAL CONDITION], and failed to
have documentation that [MEDICAL CONDITION] care return demonstrations had been monitored
for two sampled residents (Resident #9 and #7) out of 21 sampled residents. The facility
census was 65 residents.
Record review of the facility’s policy for physician’s orders dated 7/1/2016 showed:
-A qualified licensed nurse will obtain and transcribe orders according to the facility’s
Practice Guidelines;
-The nurse will review orders from the transfer record from an acute hospital or other
entity and
-A call is placed to the resident’s physician to confirm the orders and request any
additional orders as needed.
1. Record review of Resident #36’s Nursing Progress notes from the transferring facility
dated 6/5/18 showed he/she had a urinary catheter (a flexible tubing that is inserted to
the bladder to drain urine) .
Record review of the resident’s Nursing Progress notes from the transferring facility
dated 6/23/18 at 8:00 A.M. showed he/she had a urinary catheter.
Record review of the resident’s transferring facility’s Medication review report dated
6/25/18 did not include instructions for physician’s orders for the resident’s urinary
catheter or for the care and monitoring of the resident’s urinary catheter
Record review of the resident’s Admission record showed the resident was admitted to the
facility on [DATE] with the following Diagnoses: [REDACTED].
-Heart failure;
-Protein-calorie malnutrition (imbalances in a person’s intake of food and/or the ability
to absorb nutrients);
-Pressure ulcer of the sacral region (an injury to skin and underlying tissue resulting

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265362

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

MEADOW VIEW OF HARRISONVILLE HEALTH & REHAB

STREET ADDRESS, CITY, STATE, ZIP

2203 EAST MECHANIC STREET
HARRISONVILLE, MO 64701

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0658

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 4)
from prolonged pressure the bony area of the lower spine) and
-[MEDICAL CONDITION] ([MEDICAL CONDITION]- an [MEDICAL CONDITION] lung disease that
causes obstructed airflow from the lungs).
Record review of the resident’s Admission Minimum Data Sheet (MDS-a federally mandated
assessment tool to be completed by facility staff for care planning) dated 7/3/18 showed
he/she:
-Was unable to complete the Brief Interview for Mental Status (BIMS);
-Needed the staff’s guidance with decisions;
-Needed assistance of one to two nursing staff for Activities of Daily Living (ADL’s);
-Was frequently incontinent of bowel and
-Had an indwelling urinary catheter which drained into a urinary drainage bag.
Record review of the resident’s Care plan for ADL’s dated 7/6/18 showed the resident;
-Had a urinary indwelling catheter;
-The facility nursing staff were to provide care routinely and as needed;
-The nursing staff were to notify the residents nurse of leakage around the catheter and
-The resident complained of pain or discomfort from the urinary catheter.
Record review of the resident’s Nurses Treatment Administration Record (TAR) dated 6/26/18
showed the resident did not have physician’s orders for the care of an indwelling urinary
catheter with a urinary drainage bag.
Record review of the resident’s (MONTH) (YEAR)’s Physician’s Order Sheet (POS), showed the
resident:
-Had no physician’s orders for an indwelling urinary catheter;
-Had no physician’s orders for changing the urinary catheter and
-Had no physician’s orders for care and cleaning of a urinary catheter.
Record review of the resident’s nursing progress notes dated 7/1/18 to 7/12/18 showed the
resident had an indwelling urinary catheter.
Record review of the resident’s a SBAR (acronym for Situation, Background, Assessment, and
Recommendation) communication form dated 7/13/18 at 10:00 P.M., showed he/she:
-Was found on the floor;
-Had [MEDICAL CONDITION] related to [MEDICAL CONDITION];
-Vital signs were within normal limits;
-Had pulled out the urinary catheter with the indwelling balloon inflated; and
-He/she denied pain;
-The resident’s physician’s office had been notified; and
-The physician’s nurse practitioner responded, and gave an order for [REDACTED].
Record review of the resident’s nursing notes dated 7/13/18 documented during the night
shift showe d:
-The resident had been found on the floor with her head and shoulders on the bedside fall
mat;
-He/she had pulled out the indwelling urinary catheter out a second time with the balloon
inflated;
-He/she had skin tears to both lower legs;
-The nurse had assessed the resident;
-The nurse initiated neurological checks and vital signs per protocol;
-The nurse had found and treated skin tears on the resident’s legs;
-The nurses had called the resident’s Physician’s Nurse Practitioner and received an order
to replace the urinary catheter;
-The nurse had replaced the urinary catheter per the Nurse Practitioner’s order;
-The resident was then found at 10:45 P.M. near the door of his/her room;
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265362

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

MEADOW VIEW OF HARRISONVILLE HEALTH & REHAB

STREET ADDRESS, CITY, STATE, ZIP

2203 EAST MECHANIC STREET
HARRISONVILLE, MO 64701

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0658

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 5)
-He/she had pulled the urinary catheter out with the balloon inflated a second time;
-The resident was taken to the nursing station due to restlessness;
-The resident’s responsible party was notified and they said they would discuss what
interventions could be used with the resident;
-The resident started to get sleepy about 1:00 A.M. on 7/14/18; and the resident was
placed back in bed with neurological checks and vital signs continuing.
Record review of the resident’s (MONTH) (YEAR)’s POS showed a physicians order to
discontinue the Urinary catheter due to the resident’s refusal on 7/23/18.
During an interview on 10/3/18 at 8:34 A.M., Licensed Practical Nurse (LPN) A said:
-The resident’s Urinary catheter orders should be put on the POS at admission;
-The resident should be assessed and if there was no Physician’s order on the transfer
document the nurse should request and order from the resident’s physician; and
-The admitting nurse should make sure the orders are complete, they should have included
the size of the urinary catheter, when it should have been changed, and the care
instructions.
During an interview on 10/3/18 at 8:50 A.M. Registered Nurse (RN) A said:
-A resident with a urinary catheter should have an Physicians order written on the
resident’s POS;
-Physician’s orders that should have been included on the POS would be the size of the
urinary catheter the inflation amount of the indwelling balloon;
-The resident then would have orders for the frequency the urinary catheter was to be
changed, when the drainage bag should be changed and the types of drainage bags the
resident should be using; and
-The care instructions should be on the POS also, along with the [DIAGNOSES REDACTED].
During an interview on 10/3/18 at 9:10 A.M., LPN B said:
-The nurse should have first the physician’s order for the resident to have a urinary
catheter;
-The resident should have other orders for the frequency of urinary catheter changes;
-There should be a physician’s order for the type of urinary catheter, the size and the
amount of sterile water to put into the indwelling balloon;
-There should of be a physician’s order for cares and what the physician wants to be used
to clean the tubing;
-The urinary catheter cares would also needed to be care planned.
During an interview on 10/3/18 at 12:26 P.M. the resident’s physician A said, He/She:
-Expected to be notified if a resident has transferred to the facility to with a urinary
catheter;
-When the resident orders needed to be continued, the orders should have been reviewed
with him/her, then transcribed to the facilities POS.
-The staff did notify him/her that the resident arrived at the facility with a urinary
catheter on admission.
During an interview on 10/3/18 at 1:28 P.M., the Director of Nursing (DON) said:
-Expected the staff to do a head to toe assessment using the check in assessment sheet
when doing a new admit;
-The check in sheet has a place for the type and size of a urinary catheter;
-Expected the nursing staff to transcribe the orders to our POS’s correctly;
-If a physician’s order was not on the transfer document for a urinary catheter he/she
would expect the staff to notify the resident’s physician and request a physician’s order
for the urinary catheter and the cares required for it.
2. Record review of Resident #9’s Admission Face sheet showed the resident was admitted to
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265362

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

MEADOW VIEW OF HARRISONVILLE HEALTH & REHAB

STREET ADDRESS, CITY, STATE, ZIP

2203 EAST MECHANIC STREET
HARRISONVILLE, MO 64701

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0658

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 6)
the facility on [DATE] with [DIAGNOSES REDACTED]. and loss of interest),[MEDICAL
CONDITION] with septic shock (life threatening infection),
Record review of the resident’s care plan dated 3/18/18 showed the resident did not have a
care plan for his/her [MEDICAL CONDITION].
Record review of the resident’s discharge MDS dated [DATE] showed the resident;
-Was not cognitively impaired and has a BIMS score of 15 and was able to make own
discussion,
-Had a ostomy
-Required limited staff assistance with toileting and cares.
Record review of the resident care plan conference summary dated 6/20/18 showed; the staff
was to continue with bowel and bladder monitoring. No other care plan updated found
related to the resident [MEDICAL CONDITION] in his/her medical chart.
Record review of the resident’s Nursing weekly skin integrity tool dated 8/15/18 showed
the resident had staples down his/her abdomen, also had redness at the first three staples
site, his/her [MEDICAL CONDITION] (a surgical procedure in which a piece of the ileum
(lower small intestine) is diverted to an artificial opening in the abdominal wall for the
feces to come out instead of the rectum) was on the right side of his/her abdomen.
Record review of the resident’s nursing weekly skin integrity tool dated 8/7/18 showed the
resident had staples down his/her abdomen staples down abdomen no other documentation
noted.
Record review of the resident’s readmitting POS dated 8/26/18 showed physician’s orders
for;
-[MEDICAL CONDITION]/[MEDICAL CONDITION] care was to keep ostomy clean and dry ([MEDICAL
CONDITION]).
Record review of the resident’s TAR dated (MONTH) (YEAR) showed;
-On 8/7/18 the resident’s staples to his/her abdomen, staff are to monitor for signs and
symptoms of infection every shift, and
-From 8/7/18 to 8/15/18 [MEDICAL CONDITION] care every shift and as needed
-On 8/26/18, keep the resident’s ostomy clean and dry and had only been documented on the
day shift,
-No documentation related to the resident providing self-care of his/her [MEDICAL
CONDITION].
Record review of the resident’s Nursing Collection data tool dated 8/26/18 showed the
resident was readmitted to the facility, his/her bowel pattern section had documentation
that the resident had a [MEDICAL CONDITION], no other documentation related to his/her
ostomy.
Record review of the resident’s Nursing Collection Data Tool dated 8/30/18 showed the
resident was readmitted to the facility, his/her bowel elimination section had
documentation that the resident had a ostomy was present – [MEDICAL CONDITION], no other
documentation related to his/her ostomy.
Record review of the resident’s Physician’s History and Physical assessment dated [DATE]
showed the resident;
-Had a readmission and was seen 8/27/18, back in facility times 24 hours,
-Physician had discussed with the resident the risk of getting dehydrated due to his/her
[MEDICAL CONDITION],
-On 7/29/18, the nurse had notified the resident’s physician about the resident’s abdomen
had been ridged and his/her bowel sounds was hypoactive and the resident had also been in
pain,
-Had been transferred to the hospital with a [DIAGNOSES REDACTED].
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265362

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

MEADOW VIEW OF HARRISONVILLE HEALTH & REHAB

STREET ADDRESS, CITY, STATE, ZIP

2203 EAST MECHANIC STREET
HARRISONVILLE, MO 64701

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0658

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 7)
-Then transferred to another hospital were he/she had surgery for [REDACTED].
-Problem list showed the resident had an ischemic bowel with a total colectomy on 7/29/18
and the Ostomy bag needed to be change as needed.
Record review of the resident’s Nursing Collection Tool dated 9/8/18, showed the resident;
-Had been readmitted : and the section on the tool labeled bowel elimination pattern had
documentation showing the resident had a ostomy that was present
-[MEDICAL CONDITION] medical necessary documentation: please summarize any medical
condition that would exceed routine care and require the skills of a licensed nurse.
Documentation should include assessment, planning, and any interventions required to
administer care: the staff wrote [MEDICAL CONDITION] care,
-Under the nurse’s comments was documentation that the resident had been readmitted from
the hospital for abnormal labs and had undissolved stitches at the [MEDICAL CONDITION]
site,
-Had nursing evaluation of his/her bowels dated 9/8/18 showed the resident had recent
surgery on 7/29/18 for a right hemicolectomy (is a surgical procedure that involves the
removal of the cecum (a pouch connected to the junction of the small and large
intestines), the ascending colon (the first part of the large intestine, which passes
upward from the cecum on the right side of abdomen), the hepatic colon (where the
ascending colon joins the [MEDICATION NAME] colon), the first third of the [MEDICATION
NAME] colon, and part of the terminal ileum, along with the fat and lymph nodes) with an
[MEDICAL CONDITION].
-Had nursing evaluation of his/her bowels dated 8/26/18 showed the resident had recent
surgery on 7/29/18 for a right hemicolectomy with an [MEDICAL CONDITION]
-Nursing staff was to change and empty his/her [MEDICAL CONDITION] bag as needed.
Record review of the resident’s Certified Nursing Assistant (CNA) daily skin inspection
record for (MONTH) (YEAR) showed no documentation of the resident’s [MEDICAL CONDITION]
for the three shifts.
Record review of the resident’s medical record showed the resident had hospital discharge
notes dated from 9/5/18 – 9/8/18. He/she was admitted to the hospital with [REDACTED]. Had
increased output of loose stool through his/her [MEDICAL CONDITION], gastric pathogen
panel was negative. Had a wound care consulted to manage [MEDICAL CONDITION] due to
concerns for leakage of the stool.
During an interview on 9/28/18 at 11:42 A.M. the resident said ostomy care was very new
for him/her, was not comfortable with the smell from the [MEDICAL CONDITION] and with
his/her body image at this time. Denied any complaint of redness or pain at the site.
He/she said staff had been providing care for his/her ostomy.
During an interview on 9/28/18 at 12:00 P.M., RN A said;
-The CNAs provide the care for the residents with [MEDICAL CONDITION],
-CNA’s would apply skin prep to the ostomy area and place a new bag as needed, and would
also drain or burp the ostomy bag,
-The facility was able to obtain [MEDICAL CONDITION]’s bag that did not required to be
changed every day,
-The resident does not have a physician’s order for the licensed nursing staff to assess
the resident stoma or provided [MEDICAL CONDITION] care,
-RN A said if he/she happen to be in the resident’s room during [MEDICAL CONDITION] care,
then he/she would assess the resident stoma site at that time.
Record review of the resident’s POS for 10/18 showed the resident did not have physician’s
orders for the care or monitoring of his/her [MEDICAL CONDITION]/[MEDICAL CONDITION].
3. Record review the Resident #7’s Face sheet showed the resident;
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265362

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

MEADOW VIEW OF HARRISONVILLE HEALTH & REHAB

STREET ADDRESS, CITY, STATE, ZIP

2203 EAST MECHANIC STREET
HARRISONVILLE, MO 64701

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0658

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 8)
-Was admitted to the facility on [DATE],
-Had a [DIAGNOSES REDACTED].
Record review of the resident’s medical record showed the resident had a letter showing
that his/her durable Power of Attorney (DPOA) had been activated on 4/8/18 by two
physician’s signature Status,
Record review of the resident’s Care Plan dated 5/3/16 and edited on 3/21/18, showed;
-On 9/20/18 in a handwritten note showed to continue with the resident current plan of
care,
-The resident continues to be independent with ADLs care, with supervision as indicated,
-Requires supervision for ADLs, the resident has a [MEDICAL CONDITION], he/she has been
caring for his/her own [MEDICAL CONDITION] for years without any issue,
-The resident’s goal was to maintain current level of independence through next review
date,
-The care plan intervention included;
— Daily skin checks by the CNA’s,
–Weekly and as needed skin assessments by the LPNs,
Bathing supervision and setup as needed, (MONTH) need extra encouragement to bath,
-Nursing staff are to document and report any deterioration in status to the resident’s
physician.
-Under toileting requires supervision and setup as needed: the staff wrote the resident
cares for his/her own [MEDICAL CONDITION].
Record review of the resident’s quarterly MDS dated [DATE] showed the resident;
-Was not cognitively impaired and has a BIMS score of 15 and was able to make own
discussion,
-Had a ostomy
-Required no assistance with toileting,
-Had a [DIAGNOSES REDACTED].
Record review of the resident’s medical record showed bowel evaluation was done on
9/10/18, showed the resident;
-Had short term memory only,
-Had been independent with his/her own care of his/her [MEDICAL CONDITION],
-Bowel sound had been active time four quad areas, his/her bowel movement had been soft to
medium and the color was a light to medium,
-Had no documentation showing an evaluation had been done for the resident to provide
self-care of his/her [MEDICAL CONDITION],
-Had no documentation related physician’s orders for the resident to provide his/her own
self-care,
-Had no documentation related to physician’s orders for the nursing staff to provide
ongoing assessment, monitoring and care of the resident’s [MEDICAL CONDITION] and his/her
stoma.
Record review of the resident’s Physician’s Progress Note dated 9/20/18, showed the
resident;
-Had a [MEDICAL CONDITION] located on his /her right lower Quad,
-Abdomen was soft, non-tender to touch, and
-[MEDICAL CONDITION] was intact, and the resident’s bowels sounds were active.
Record review of the residents TAR dated (MONTH) (YEAR), showed;
-The resident had no documentation for the care of his/her [MEDICAL CONDITION], or to
provide his/her own self care,
-Nursing staff were to provide weekly skin assessments.
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265362

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

MEADOW VIEW OF HARRISONVILLE HEALTH & REHAB

STREET ADDRESS, CITY, STATE, ZIP

2203 EAST MECHANIC STREET
HARRISONVILLE, MO 64701

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0658

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 9)
Record review of the resident’s Nursing Skin Checks reviewed for (MONTH) and (MONTH)
(YEAR) showed the resident skin assessments had been completed;
-Nursing documentation showed the resident had no skin issues, and on some of the skin
assessment had documented had a [MEDICAL CONDITION],
-Did not have a formal detail assessment of the stoma site or if any issue had related to
his/her [MEDICAL CONDITION],
-No documentation related to obtain a physician’s order for the resident to provide
self-care of his/her [MEDICAL CONDITION].
Record review of the resident’s POS dated 10/1/18 to 10/31/18 showed the resident;
-Had a [DIAGNOSES REDACTED].
– Had medication related to the bowels included: [MEDICATION NAME] 2 milligram (mg)
capsules, take 2 capsules by mouth after the first loose stool, then take 1 capsule by
mouth after every subsequent loose stools,
-Had no documentation related to the resident’s having physician’s orders for the resident
to provide his/her own self-care,
-Had no documentation related to the resident’s having physician’s orders for the nursing
staff to provide ongoing assessment, monitoring and care of the resident’s [MEDICAL
CONDITION] and of his/her ostomy stoma.
-Check for bowel movement (BMs) every shift, and to notify the nurse and the resident’s
physician’s if no bowel movements in three days.
During an interview on 10/03/18 at 9:43 A.M., LPN F said,
The resident does not have any odors or a problem with the [MEDICAL CONDITION],
-He/she had never seen the resident dirty or smelling; there has not been no change in
resident’s mental capacity,
-When the resident had been admitted to the facility, the resident already had the
[MEDICAL CONDITION] and was doing his/her own cares,
-Nursing staff only have to check the resident’s skin,
-CNA’s do daily skin checks and the nursing staff do weekly skin assessments,
-There were no physician’s order for treatment because the resident does the treatment
himself/herself.
During an interview on 10/3/18 at 10:07 A.M. LPN C said;
-An outside supplier supplies the resident’s [MEDICAL CONDITION] bag;
-Supplier calls to check to see if delivery of bags needed at the regular time periods,
-Nursing receives the [MEDICAL CONDITION] bags, and knows when resident needs them,
-The resident never has fecal matter or wetness at the site,
-The resident had not been formally assessed for his/her ability perform his/her own
[MEDICAL CONDITION] care,
-The resident continues to prove he/she is capable based on daily CNA’s skin checks and
nurse assessments.
During an interview on 10/03/18 at 1:01 P.M., DON said;
– When you look at the resident’s POS the [MEDICAL CONDITION] is under his/her diagnosis,
-There probably should be a physician’s order on the resident’s POS that shows the
resident was providing own self-care of his/her [MEDICAL CONDITION].

F 0689

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Ensure that a nursing home area is free from accident hazards and provides adequate
supervision to prevent accidents.

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265362

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

MEADOW VIEW OF HARRISONVILLE HEALTH & REHAB

STREET ADDRESS, CITY, STATE, ZIP

2203 EAST MECHANIC STREET
HARRISONVILLE, MO 64701

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0689

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 10)
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to ensure the
safety of one sampled resident during a transfer in order to prevent a fall from occurring
and to transfer the resident safely after initiating interventions that would prevent
further falls from the side of his/her bed (Resident #32) and to provide adequate
supervision for a resident who goes through alarmed doors to exit the building to the
parking lot that is next to a deep ditch and a busy highway for one sampled resident
(Resident #12) out of 21 sampled residents. The facility census was 66 residents.
1. Record review of Resident #32’s Face Sheet showed he/she was admitted on [DATE], with
[DIAGNOSES REDACTED].
Record review of the resident’s quarterly Minimum Data Set (MDS-a federally mandated
assessment tool to be completed by facility staff for care planning) dated 7/20/18, showed
he/she:
-Was confused with inattention and disorganized thought with behavioral symptoms;
-Needed extensive assistance with bathing, dressing toileting, bed mobility, transfers,
locomotion and used a wheelchair for mobility and did not ambulate and
-had a history of [REDACTED].
Record review of the resident’s Fall Risk assessment dated [DATE] showed a score of 24 (a
score of 10 or higher was considered at risk).
Record review of the resident’s Nursing Notes showed:
-On 7/20/18, the Certified Nursing Assistant (CNA) reported the resident fell from a
sitting position on the side of his/her bed to the fall mat while the CNA was raising the
resident’s bed to transfer him/her to his/her wheelchair. The CNA reported the resident
did not hit his/her head. The nurse documented the resident’s vital signs (blood pressure,
temperature, respirations and pulse). The resident sustained [REDACTED]. The nurse cleaned
the skin tear with normal saline, and applied opti-foam dressing. There was a small amount
of bleeding. The resident’s range of motion was within normal limits and there was no
shortening of limbs. The resident denied pain. Nursing staff assisted the resident into
his/her wheelchair. The resident’s physician and family were notified. The new
intervention to be implemented was for the resident to remain in a lying position when
raising or lowering the bed.
Record review of the resident’s Fall/Incident Investigation dated 7/20/18, showed:
-On 7/20/18 at 4:45 P.M., the CNA witnessed the resident fall in the resident’s room;
-The resident was alert and confused. There was no change in the resident’s baseline;
-The CNA was raising the resident’s bed while the resident was sitting on the side of
his/hr bed. The resident reached for something on the floor and fell from the side of the
bed onto the floor mat;
-The resident sustained [REDACTED].
-Findings showed the CNA was raising the bed while the resident was sitting on the side of
the bed (as the root cause of the resident’s fall);
-Follow up to prevent recurrence showed there was a new intervention to have the resident
in a lying position while raising and lowering the bed;
-The resident’s Fall risk (updated on 7/20/18) was 22. The resident’s Pain Evaluation,
dated 7/22/18, showed no pain complaint and
-The resident’s Care Plan was updated to show the new intervention that staff should leave
resident in a lying position when raising or lowering the bed. It also showed treatment to
the resident’s skin tear (Cleanse the resident’s right lateral elbow skin tear with normal
saline or wound cleanser, pat it dry, cover it with opti foam or equivalent dressing, and
change it every three days and as needed).
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265362

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

MEADOW VIEW OF HARRISONVILLE HEALTH & REHAB

STREET ADDRESS, CITY, STATE, ZIP

2203 EAST MECHANIC STREET
HARRISONVILLE, MO 64701

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0689

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 11)
Record review of the resident’s Care Plan showed there was no update after the resident’s
fall on 7/20/18, showing the new intervention to leave the resident laying down when
raising or lowering his/her bed.
During an observation and interview on 10/2/18 at 2:55 P.M., showed the resident:
-In a low bed (almost to the floor) with a mat on the floor;
-CNA C went into the resident’s room, put on gloves and removed the mat from the side of
the resident’s bed;
-The resident sat up on the side of his/her bed and CNA C began to raise the resident’s
bed up;
-CNA B entered the resident’s room, put on gloves and began assisting CNA C to place the
gait belt around him/her and transfer him/her to his/her wheelchair;
-Once they were finished transferring the resident, both CNA C and CNA B said:
-They were aware of the resident’s falls;
-The resident would often reach and lean forward because he/she was trying to get things;
-CNA C said he/she usually would sit the resident up on the side of the bed while they
raised the bed up to prepare to transfer; and
-CNA C was unaware that the resident was not to sit up on the side of the bed while the
bed was being raised.
During an interview on 10/3/18 at 2:14 P.M., the Director of Nursing (DON) said:
-Nursing staff should not raise the bed while the resident is sitting on the side of the
bed;
-The resident’s fall was avoidable because staff should not have raised the resident’s bed
while the resident was sitting up on the side of the bed and
-The resident’s fall interventions should be on the care plan.
Record review of the facility’s Elopement Policy dated 7/1/16 showed that residents who
eloped should be safely and timely redirected to a safe environment.
2. Record review of Resident #12’s Admission record face sheet showed he/she was initially
admitted to the facility on [DATE] with the following Diagnoses: [REDACTED].
-Delusional disorder (an unshakable belief in something untrue or not based on reality);
-Conduct disorder (a repetitive and persistent pattern of behavior in which the basic
rights of others are violated);
–Anxiety disorder (a group of mental disorders characterized by significant feelings of
anxiety and fear) and
-Restlessness and agitation: a feeling of aggravation, annoyance, or restlessness brought
on by little or no provocation).
Record review of the resident’s Risk of Elopement/Wandering was completed initially on
12/19/17 and showed:
-The resident was assessed to have poor decision making skills;
-He/she had a pertinent [DIAGNOSES REDACTED].
-He/she had been admitted or readmitted to the facility within the past 30 days and was
not accepting of the situation;
-The resident’s family/guardian preferred the resident to be on a locked Unit;
-The facility was locked and secured;
-The resident did not have a [DIAGNOSES REDACTED].
-The facility’s staff was not to allow the resident to be out of the facility without
his/her guardian.
Record review of the resident’s care plan dated 1/15/18 showed:
-The resident had altered thought processes due to paranoid [MEDICAL CONDITION];
-The resident was a risk for harm to self and others;
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265362

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

MEADOW VIEW OF HARRISONVILLE HEALTH & REHAB

STREET ADDRESS, CITY, STATE, ZIP

2203 EAST MECHANIC STREET
HARRISONVILLE, MO 64701

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0689

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 12)
-Staff was to monitor the resident for changes in cognition and to notify the resident’s
physician of his/her decline and
-The staff was to monitor for safety risks and to intervene as needed.
Record review of the resident’s Non-Emergency Ambulance Transportation from a local
hospital for transportation returning to the facility dated 2/4/18, signed by a Registered
Nurse(RN) said:
-The resident had a psych condition and was a high elopement risk and
-He/she required to be on one to one monitoring by a trained medical personnel.
Record review of the resident’s nursing notes dated 7/11/18 at 1:45 P.M. showed:
-The resident attempted to open the doors to the solarium;
-The resident was unsuccessful in the attempt to open the doors and
-He/she returned to his/her room.
Record review of the resident’s nursing notes of 7/14/18 at 9:00 P.M. showed:
-The resident opened the alarmed door at the end of hallway into the independent living
apartments;
-The resident went out through the independent living apartment doors to the parking lot;
– A staff member followed the resident into the parking lot;
-The resident became verbally and physically aggressive toward the staff;
-The resident was brought back into the building by the staff member who then
escorted the resident to their room;
-The on duty nurse notified the Director of Nursing (DON), the resident’s physician, and
the resident’s Mental Health provider;
-The resident’s physician’s on call nurse practitioner gave an order for
[REDACTED].>-The resident accepted the injection of [MEDICATION NAME];
-The resident’s mental health provider had called and had given a medication order for
[MEDICATION NAME] 1 mg orally or [MEDICATION NAME] 1 mg by injection intramuscularly (
IM-into a muscle) as needed (PRN) for 14 days and
-The resident was put on staff visual safety checks every 15 minutes for 24 hours.
Record review of the resident’s Nurse Notes dated 7/22/18 at 12:45 A.M. showed:
-The resident left the facility by the door at the end of the resident’s hallway that
opens into the independent living facility;
-The facility staff went out into the parking lot through the front door and a nurse
followed the resident out the door at the end of the hallway;
-The resident had a bag and was attempting to get into a car;
-The facility staff spoke to the resident and convinced her to return to the building,
-The DON was notified of the elopement and
-The Mental Health provider was notified of the elopement and gave an order to give the
resident an injection of [MEDICATION NAME] 1 mg IM.
Record review of the resident’s Nurse Notes dated 7/22/18 at 2:00 P.M., showed:
-The resident was on visual safety checks every 15 minutes through the day;
-The resident was going from his/her room to the dining room and
-The resident had not attempted to elope during the nursing shift.
Record review of the resident’s Nurse Notes dated 7/23/18 at 6:16 A.M. showed:
-The resident had continued on safety checks through the night and
-The resident had left his/her room through the night to go to the dining room.
Record review of the resident’s Nursing Notes dated 8/2/18 at 8:53 A.M. showed the
resident was repeatedly pushing on the solarium doors.
Record review of the resident’s Nursing Notes dated 8/2/18 at 9:15 A.M. showed the
resident was redirected by the staff when the resident attempted to leave the facility by
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265362

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

MEADOW VIEW OF HARRISONVILLE HEALTH & REHAB

STREET ADDRESS, CITY, STATE, ZIP

2203 EAST MECHANIC STREET
HARRISONVILLE, MO 64701

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0689

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 13)
the front door.
Record review of the resident’s Nurse Notes dated 8/3/18 at 11:40 A.M. showed:
-The resident pushed and hit his/her Mother;
-He/she attempted to push through his/her Father to exit the front door;
-The resident was brought back into the facility by the staff; and
-The resident was verbally abusive to the staff.
Record review of the resident’s Nurse Note dated 8/17/18 at 1:45 A.M. showed:
-The resident had left the facility through the west hallway door;
-The staff redirected the resident back into the facility;
-The staff notified the DON, Mental Health provider, the resident’s physician and the
resident’s guardian; and
-The resident was put on every 15 minute safety checks.
Record review of the resident’s Nurse Notes dated 8/19/18 at 12:00 A.M. showed the
resident:
-Was on 15 minute safety checks;
-Was in his/her room packing a bag; and
-Had to be convinced it was too late to leave the facility.
Record review of the resident’s Quarterly MDS dated [DATE] showed the resident:
-Was cognitively intact;
-Required supervision or oversight on and off his/her Unit/hallway;-Was continent of bowel
and bladder;
-Had received antipsychotic (a medication used to treat psychiatric disorders) 7 out of 7
days during the look back period; and
-Had received antianxiety (a medication which has a calming effect) medication 7 out of 7
days during the look back period.
During a interview on 10/2/18 at 9:48 A.M. Licensed Practical Nurse (LPN) B said;
-When facility staff had noticed the resident near a door, the staff had always attempted
to redirect the resident; and
-Waits until the staff were busy to make his/her attempt to leave the facility.
During an interview on 10/2/18 at 10:02 A.M. LPN A said we had not received any special
training to care for the resident with the [DIAGNOSES REDACTED].
During an interview on 10/3/18 at 1:28 P.M. with the Director of Nursing (DON) said:
-Expected the staff to redirect the resident when they saw him/her near an exit door;
-Expected the staff to use the facility’s policy on elopement/wandering when a resident
left the facility unattended;
-Expected the staff to notify the DON, the resident’s physician and the guardian when a
resident elopes; and
-Expected the staff to use the interventions in the resident’s care plan to prevent future
attempted elopements.

F 0761

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Ensure drugs and biologicals used in the facility are labeled in accordance with
currently accepted professional principles; and all drugs and biologicals must be stored
in locked compartments, separately locked, compartments for controlled drugs.

Based on observation, interview and record review, the facility failed to ensure safe
storage and labeling of medication and monitoring of over the counter medication for

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265362

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

MEADOW VIEW OF HARRISONVILLE HEALTH & REHAB

STREET ADDRESS, CITY, STATE, ZIP

2203 EAST MECHANIC STREET
HARRISONVILLE, MO 64701

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0761

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 14)
expiration dates for 4 out of 9 medication carts. The facility census was 66 residents.
1. Observation on 10/01/18 at 12:17 P.M. of the Certified Medication Technician (CMT) cart
on The Memory Care Unit showed one Milk of Magnesia (MOM) had an expiration date of 2/2018
and had an open date of 6/18.
During an interview on 10/1/18 at 12:17 P.M. , CMT A said:
-The medication carts are checked monthly for expired medication and
-The MOM should have been pulled and not used.
Observation on 10/01/18 at 12:22 P.M. of the CMT Medication Cart on the East hall showed:
-One bottle of liquid tears (eye drops) with no open date on the vial but was dated on box
and
-One bottle of MOM had an expiration date of 2/2018 and had an open date of 8/18.
During an interview on 10/1/18 at 12:22 P.M. , CMT B said:
-The medication carts are checked monthly for expired medications and
-The MOM should have been pulled and not used.
Observation on 10/01/18 on 12:37 P.M. of the CMT Medication Cart on the West hall showed:
-Two open bottles of liquid tears with no opened date on the vials and
-One open bottle of nasal spray with no opened date on the bottle.
During an interview on 10/3/18 at 1:30 P.M., the Director of Nursing (DON) said:
-All medications bottles should have dates on the medication bottles and boxes to show the
date it was opened;
-It was not appropriate to open an expired medication and date that medication bottle with
the date it was opened after the expiration date and administer the expired medication to
the residents and
-The nurses and CMTs medication carts are checked monthly for expired medication and the
expired medications are to be removed from the medication cart and disposed of
appropriately.

F 0804

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Ensure food and drink is palatable, attractive, and at a safe and appetizing
temperature.

Based on observation, interview, and record review the facility failed to ensure the
pureed (a paste or thick liquid suspension usually made from cooked food that was ground
finely) vegetables were flavored correctly according to the recipe. This practice
potentially affected four residents with pureed diets. The facility census was 66
residents
1. Record review of the facility’s undated recipe for pureed vegetables showed the
following:
-Ingredients: cooked vegetables that were drained, bread slices, vegetable juices and
melted butter or margarine;
-Method of preparation: Place vegetables in the food processor and blend;
-Add bread and blend;
-Add a small amount of juice, and blend, alternate adding juice and blending until
consistency is smooth;
-Add butter or margarine, and blend;
-Transfer to serving pan(s) and cover with foil;
-Reheat; and

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265362

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

MEADOW VIEW OF HARRISONVILLE HEALTH & REHAB

STREET ADDRESS, CITY, STATE, ZIP

2203 EAST MECHANIC STREET
HARRISONVILLE, MO 64701

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0804

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 15)
-Hold on steam table above 160 degrees Fahrenheit.
-Note: use only the amount of liquid necessary to puree the product. Do not increase or
decrease the amount of vegetables or bread.
Observation of the process of pureeing the vegetables showed the following:
-At 11:42 A.M., Dietary Cook (DC) A pureed the vegetables without recipe book open;
-At 11:42 A.M., DC A did not add vegetable juice or melted margarine/butter; and
-At 11:42 A.M., DC A placed the pureed vegetables in a pan and placed the pan on the steam
table without tasting the pureed vegetables.
During a taste test on 10/1/18 at 11:49 A.M., the pureed vegetables tasted bland.
During an interview on 10/1/18 at 11:51 A.M. DC A said he/she did not add margarine to the
pureed veggies which caused them to be bland.
During an interview on 10/1/18 at 1:40 P.M., the Dietary Manager (DM) said employees are
trained in making pureed foods and using the recipes in the recipe book is a part of that
training.

F 0805

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Ensure each resident receives and the facility provides food prepared in a form
designed to meet individual needs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview, and record review the facility failed to ensure the
pureed (a paste or thick liquid suspension usually made from cooked food that was ground
finely) food (chicken) was smooth and without visible bits of food within those foods.
This practice potentially affected four residents with physician’s orders [REDACTED].
1. Record review of the facility’s undated recipe for pureed chicken showed the following:
– Ingredients: cooked meat or poultry, broth and bread slices;
-Method of preparation: Place meat in the food processor and grind;
-Add bread and blend;
-Add four ounces or a ? cup of liquid, blend and continue to alternate adding ? cup of
liquid until consistency is smooth and between pudding and mashed potato consistency;
– Transfer to serving pan(s) and cover with foil;
– Reheat; and
– Hold on steam table above 165 degrees Fahrenheit.
– Note: use only the amount of liquid necessary to puree the product. Do not increase or
decrease the amount of meat or bread.
Observation on 10/1/18 at 11:33 A.M., showed Dietary Cook (DC) A pureed chicken with no
recipe book open and he/she did not taste the pureed chicken after he/she was finished.
During a taste test on 10/1/18 at 11:47 A.M., showed chunky pieces of chicken in the
pureed chicken.
During an interview on 10/1/18 at 11:49 A.M., DC A apologized for the chunkiness in the
pureed chicken.
During an interview on 10/1/18 at 11:49 A.M., the Dietary Manager (DM) said the chicken
needed to be pureed a little longer.
Observation on 10/1/18 at 11:54 A.M., showed the DM also pureed the chicken, also without
the recipe book open.
During an interview on 10/1/18 at 1:40 P.M., the DM said employees are trained in making
pureed foods and using the recipes in the recipe book is a part of that training.

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265362

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

MEADOW VIEW OF HARRISONVILLE HEALTH & REHAB

STREET ADDRESS, CITY, STATE, ZIP

2203 EAST MECHANIC STREET
HARRISONVILLE, MO 64701

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0805

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

F 0812

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Many

Procure food from sources approved or considered satisfactory and store, prepare,
distribute and serve food in accordance with professional standards.

Based on observation, interview and record review, the facility failed to prevent the
following: a buildup of debris and grime on the floors in the cooler room, the dry storage
area and under the automated dishwasher; ensure utensils were stored free of potential
contamination by standing water in the utensil drawer; ensure utensil handles were
maintained in an easily cleanable manner; a buildup of grease behind the stove and the
convection oven; ensure a thermometer was calibrated (to determine, check, or rectify the
graduation of any instrument) properly; ensure there was adequate light in the area where
the food processor was used; ensure the emergency light fixture over the food processor
area was free of dust; and to label a container of sherbet (a frozen dessert made
primarily of fruit juice and sugar, but also containing milk or egg-white or gelatin) with
a date and a name of which person or department it belonged to, in the facility
staff/resident food storage refrigerator. This practice potentially affected all
residents. The facility census was 66 residents.
1. Observation on 10/1/18 from 9:32 A.M. through 1:05 P.M., during the lunch meal
preparation, showed the following:
– At 9:39 A.M., grime was present on floor of the dishwashing area, and in dry storage
room;
– At 9:42 A.M., Dietary Cook (DC) A said the dietary staff try to scrub under the sinks
about once per week;
– At 9:50 A.M., two utensils with handles that were not easily cleanable present in the
utensil storage drawer and water was at bottom of utensil drawer with numerous scoops, and
other utensils;
– At 9:51 A.M., the Dietary Manager (DM) acknowledged the observation;
– At 10:00 A.M., a buildup of grease was observed on the wall behind the oven, on the oven
components and on the floor behind the oven;
– At 10:28 A.M., 10 single serving containers of margarine and cobwebs, were present on
the floor of the cooler room with other debris;
– At 10:31 A.M., the DM acknowledged that the floors in the cooler room were swept daily
but some dietary staff were not getting under the refrigerators like they should;
– At 10:36 A.M., dust was present on the light fixtures over the cooking area and over the
dishwashing area and on the emergency light fixture;
-At 10:37 A.M., the DM said the maintenance department cleaned those fixtures;
– At 11:02 A.M., the temperature of the cooked chicken was 188.5 ?F (degrees Fahrenheit)
measured with the surveyor’s thermometer and the temperature was 121-122 ?F when measured
with the facility’s thermometer;
– At 11:05 A.M., DC A said that thermometer may not have been calibrated
recently;
– At 11:09 A.M., an unlabeled sherbet container was present in the staff and resident
guest food refrigerator located in the employee breakroom;
– At 11:13 A.M., the Social Worker said that residents who receive food from visitors,
sometimes used the employee breakroom refrigerator to store their received food with their
name and dates on it;
– At 1:36 P.M., the DM said cleaning under the refrigerators should be done weekly, and
cleaning should be done by both dietary shifts; and

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265362

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

MEADOW VIEW OF HARRISONVILLE HEALTH & REHAB

STREET ADDRESS, CITY, STATE, ZIP

2203 EAST MECHANIC STREET
HARRISONVILLE, MO 64701

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0812

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Many

(continued… from page 17)
– At 1:54 P.M., the Activities Assistant said the sherbet in the freezer did not belong to
the activities department.
Record review of the 1999 and 2009 Food and Drug Administration (FDA) Food Code and
Missouri Food Codes, showed:
– In Chapter 3-305.14, During preparation, unpackaged Food shall be protected from
environmental sources of contamination.
– In Chapter 4-202.11, regarding Food-Contact Surfaces; Multi-use Food-Contact Surfaces
shall be: (1) Smooth; (2) Free of breaks, open seams, cracks, chips, inclusions, pits, and
similar imperfections; (3) Free of sharp internal angles, corners, and crevices; and 4)
Finished to have smooth welds and joints;
– In 4-203.11 B) Temperature Measuring Devices, Food.
Food temperature measuring devices that are scaled only in Fahrenheit shall be accurate to
?2 ?F in the intended range of use.
– In Chapter 4-601.11, Equipment Food-Contact Surfaces and Utensils shall be clean to
sight and touch.
– In Chapter 4-602.13, non-Food-Contact Surfaces of Equipment shall be cleaned at a
frequency necessary to preclude accumulation of soil residues;
– In Chapter 6-501.12, paragraph A, The physical facilities shall be cleaned as often as
necessary to keep them clean.

F 0814

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Many

Dispose of garbage and refuse properly.

Based on observation, interview and record review, the facility failed to ensure the
dumpster was kept closed on 9/27/18 and 10/1/18. The facility census was 66 residents.
1. Observations on 9/27/18 at 12:41 P.M., and 1:13 P.M., showed the dumpster lid open.
Observations on 10/1/18 at 9:04 A.M., 9:42 A.M., 10:05 A.M., 10:46 A.M., 11:10 A.M., 11:39
A.M., and 12:17 P.M., showed the dumpster lid open.
During an interview on 10/1/18 at 1:35 P.M. Dietary Cook (DC) A said the dietary
department had been advising other departments to keep the dumpster lid closed.
Record review of the 2009 FDA Food Code, Chapter 5-501.113, showed the following:
Receptacles and waste handling units for refuse, recyclables, and returnables, shall be
kept covered: B) with tight-fitting lids or doors if kept outside the Food Establishment.

F 0880

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Provide and implement an infection prevention and control program.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to implement
infection control practices to prevent cross contamination by failing to appropriately
wash hands and change gloves during [MEDICAL CONDITION] care (a surgical procedure to
create an opening through the neck into the trachea windpipe-a tube is placed through this
opening to provide an airway and to remove secretions from the lungs) for one sampled
resident (Resident #4); during wound care for two sampled resident (Resident #69 and #50);
during a transfer for two sampled resident (Resident #32 and #50); and during blood sugar
monitoring for two sampled resident (Resident # 34 and #15) out of 21 sampled residents.

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265362

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

MEADOW VIEW OF HARRISONVILLE HEALTH & REHAB

STREET ADDRESS, CITY, STATE, ZIP

2203 EAST MECHANIC STREET
HARRISONVILLE, MO 64701

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0880

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 18)
The facility census was 66 residents.
Record review of the facility Infection Prevention Hand Hygiene/Handwashing policy and
procedure dated 9/2011, showed hand hygiene/handwashing technique will be accomplished at
all times that handwashing is indicated. Procedures:
-Hand hygiene/Handwashing is done before resident contact, after contact with soiled or
contaminated articles, such as articles that are contaminated with bodily fluids, after
patient/resident contact, after contact with a contaminated object or source where there
is a concentration of micro organisms, such as mucous membranes, non-intact skin, body
fluids or wounds.
-Handwashing/Hand hygiene is done after removal of medical/surgical or utility gloves,
contact with a patient’s/resident’s intact skin, performing physical examinations, lifting
residents/patient while in bed, and when in contact with environmental surfaces in the
immediate vicinity of patients/residents.
-When hands are visibly soiled , wash hands with either a non-antimicrobial soap and water
or an antimicrobial soap and water.
-If hands are not visibly soiled, use an alcohol based rub for routinely decontaminating
hands in all other clinical situations.
Record review of the facility Indications for Glove Use policy and procedure dated 9/2011,
showed standard/universal precautions are intended to prevent the exposure of non-intact
skin and mucous membranes of health care workers to others blood and body fluids.
Personnel will routinely use appropriate precautions when contact with the blood or bodily
fluids except sweat of any patient/resident is likely. Gloves are an appropriate barrier
for protection from blood or body substances likely to soil the hands.
-Gloves are worn when touching blood and body fluids, except sweat; touching mucous
membranes or non-intact skin; touching urine, stool or vomit; handling items or
environmental surfaces soiled with blood or body fluids, except sweat; when performing
venipuncture and other vascular access procedures and anytime required by the facility
policy, procedure or regulations.
-Gloves are changed between residents/patients, if contaminated with blood or body fluids
before touching other parts of the same resident/patient.
-Hands are washed immediately after gloves are removed, before contact with another
resident/patient or the environment.
-Hands are washed or decontaminated prior to donning gloves.
1. Record review of Resident #4’s Face Sheet showed the resident was was admitted to the
facility on [DATE], with [DIAGNOSES REDACTED].
Record review of the resident’s quarterly Minimum Data Set (MDS a federally mandated
assessment tool to be completed by facility staff for care planning) dated 9/10/18, showed
the resident:
-Was alert and oriented with little confusion.
-Needed total assistance with bed mobility, transfers, dressing, bathing, toileting and
mobilized in a wheelchair.
-Had upper and lower extremity limitations.
Record review of the resident’s physician’s orders [REDACTED].
Observation on 10/03/18 at 9:18 A.M., showed the resident was sitting up in his/her
wheelchair in his/her room. Registered Nurse (RN) A and Licensed Practical Nurse (LPN) B
came into the resident’s room and washed their hands, turning off the water with a paper
towel. Supplies were laying on a clean towel on the resident’s tray table. RN A laid a
sterile towel down on the resident’s bed and laid supplies there (gauze and cotton pads).
RN A then:
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265362

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

MEADOW VIEW OF HARRISONVILLE HEALTH & REHAB

STREET ADDRESS, CITY, STATE, ZIP

2203 EAST MECHANIC STREET
HARRISONVILLE, MO 64701

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0880

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 19)
-Took out sterile gloves and put them on. He/She poured sterile water in one container and
peroxide in another.
-He/she then changed sterile gloves and removed the resident’s trachea cannula tube and
removed the old dressing (from around the cannula). He/she removed his/her gloves and
discarded them.
-RN A then, without washing or sanitizing his/her hands, opened a package containing
sterile gloves and put them on. He/she then cleaned the cannula tubing in the peroxide
solution. LPN B poured saline over and into the cannula tubing as RN A held the cannula
tube.
-RN A then discarded his/her gloves and without washing or sanitizing his/her hands,
opened another package of sterile gloves, put them on and cleaned the resident’s skin
around the [MEDICAL CONDITION] (using a cotton gauze) with saline, then cleansed the
[MEDICAL CONDITION] itself (the resident began to cough and RN A stopped and allowed the
resident to calm).
-RN A continued to clean the area using one gauze per swipe and disposed of the gauze.
-RN A then, without de-gloving, washing or sanitizing his/her hands, placed a new pad
around the [MEDICAL CONDITION] and re-inserted the [MEDICAL CONDITION] tubing cannula. RN
A then de-gloved.
-RN A discarded his/her gloves, without washing or sanitizing his/her hands, he/she opened
another package of sterile gloves and put them on then placed the suction tubing in saline
(with the machine turned on ) and began to suction the resident’s [MEDICAL CONDITION].
When the resident said she felt that all of the phlegm was out RN A stopped suctioning.
-RN A de-gloved the left hand and placed another glove on it, then changed the resident’s
neck strap.
-RN A then assisted the resident to leave the room.
During an interview on 10/3/18 at 9:40 A.M., RN A said:
-He/she brought additional sterile gloves in the room as a precaution.
-After he/she cleansed the resident’s tube and after cleaning around the resident’s
[MEDICAL CONDITION] site, he/she should have sanitized his/her hands.
-When he/she read their policy, the policy did not show that hand washing was necessary,
but since it is a sterile procedure, he/she should have used hand sanitizer after changing
from a dirty to clean process.
-He/she was nervous.
During an interview on 10/03/18 at 2:14 P.M., the Director of Nursing (DON) said:
-Their policy for [MEDICAL CONDITION] care and his/her expectation is for the nurse to
wash hands upon entry. -The RN should have washed or sanitized her hands after cleaning
the resident’s [MEDICAL CONDITION] site and after cleansing the cannula, before starting
the clean processes.
-According to their policy the nurse should have suctioned the resident first, but he/she
should have washed his/her hands prior to suctioning the resident and again once the
process was completed.
2. Record review of Resident #69’s Face Sheet showed the resident was admitted to the
facility on [DATE], with [DIAGNOSES REDACTED].
Record review of the resident’s quarterly MDS dated [DATE], showed the resident:
-Was alert with inattention and disorganized thoughts and memory loss.
-Needed extensive assistance with bathing, dressing, transfers, toileting and mobilized in
a wheelchair.
-Was at risk for wounds and had a skin tear that the facility was treating with ointment
and dressings.
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265362

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

MEADOW VIEW OF HARRISONVILLE HEALTH & REHAB

STREET ADDRESS, CITY, STATE, ZIP

2203 EAST MECHANIC STREET
HARRISONVILLE, MO 64701

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0880

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 20)
Observation on 9/28/18 at 8:35 A.M., showed RN B brought the resident into the resident’s
room to complete wound care. He/She had placed his/her supplies on a barrier on the
resident’s tray table and then washed his/her hands, turning the water off with a paper
towel and gloved. The resident was sitting up in his/her wheelchair. RN B then:
-Took the resident’s sock off of his/her left foot and rolled up the compression sock on
the resident’s left leg. There was a bandage on the resident’s anterior left calf that RN
B removed. He/she then de-gloved.
-Without washing or sanitizing his/her hands, RN B gloved then used wound cleanser to
spray onto the resident’s leg wound and wiped it using sterile gauze.
-After cleaning the wound and surrounding area, RN B removed his/her gloves.
-Without washing or sanitizing his/her hands, RN B opened an alcohol wipe, cleaned a pair
of scissors, discarded the wipe, and opened the new dressing.
-RN B then gloved, cut the Xeroform dressing (a sterile, non-adhering, protective gauze
dressing that provides a moist environment for healing), placed Santyl (an ointment used
to help break up and dissolve dead skin) on the Xeroform, then placed the Xeroform on the
resident’s wound.
-RN B then removed his/her gloves, and without washing or sanitizing, put on another pair
of gloves and placed the Xeroform dressing over the resident’s wound.
-RN B de-gloved and dated the dressing.
-RN B then put on another pair of gloves and without washing or sanitizing his/her hands,
placed a dry gauze on a red area on the resident’s skin that was above the dressing and
taped the area to hold it down. He/she then removed his her gloves.
-RN B then put on another pair of gloves and without washing or sanitizing his/her hands
pulled the resident’s compression sock and pant leg down and put his/her sock back on.
-RN B then washed his/her hands turning off the water with a paper towel.
During an interview on 9/28/18 at 8:50 A.M., RN B said:
-He/She should have sanitized his/her hands (or washed them) every time he/she changed
his/her gloves.
-The reason that he/she did not sanitize his/her hands (during the wound care treatment)
was because there was no hand sanitizer in the supplies that he/she brought into the
resident’s room and he/she thought about going to get it but did not.
3. Record review of Resident #32’s Face Sheet showed the resident was admitted on [DATE],
with [DIAGNOSES REDACTED].
Record review of the resident’s quarterly MDS dated [DATE], showed the resident:
-Was confused with inattention and disorganized thought with behavioral symptoms.
-Needed extensive assistance with bathing, dressing toileting, bed mobility, transfers,
locomotion and used a wheelchair for mobility and did not ambulate.
During an observation and interview on 10/2/18 at 2:55 P.M., showed the resident was in a
low bed (almost to the floor) with a mat on the floor:
-Certified Nursing Assistant (CNA) C went into the resident’s room and without washing or
sanitizing his/her hands put on gloves and removed the mat from the side of the residents
bed.
-The resident sat up on the side of his/her bed and CNA C began to raise the resident’s
bed up.
-CNA B entered the resident’s room and without washing or sanitizing her hands, he/she put
on gloves and began assisting CNA C to place the gait belt around him/her and transfer
him/her to the wheelchair.
-Once they were finished transferring the resident, both CNA C and CNA B said that they
were supposed to wash their hands upon entering the resident’s room prior to providing
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265362

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

MEADOW VIEW OF HARRISONVILLE HEALTH & REHAB

STREET ADDRESS, CITY, STATE, ZIP

2203 EAST MECHANIC STREET
HARRISONVILLE, MO 64701

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0880

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 21)
care and after they completed care, before leaving the resident’s room.
4. Record review of the Resident #50 Face sheet showed the resident was readmitted to the
facility on [DATE], original date 5/17/13 with [DIAGNOSES REDACTED].
Record review of the resident’s Care Plan dated 4/19/18 showed the resident:
-Had excoriation gaulding on buttock was updated on 5/17/18, was started on [MEDICATION
NAME] (an antibiotic) 500 milligrams (mg) daily x 10 days for wound infections to his/her
coccyx, and [MEDICATION NAME] in place times 4 weeks.
-An update on 5/18 showed the resident was sent to the hospital related to a leaking
catheter.
-On 5/20/18 showed to continue [MEDICATION NAME] until completed.
-On 7/8/18 was sent to the hospital for evaluation and treatment.
-Goal was: gaulded/excoriated area to buttocks will receive treatment as ordered:
–Notify the resident’s physician of decline in condition of his/her skin, any open areas
to skin as indicated.
–Updated on 7/14/18 -the resident was readmitted : coccyx/bilateral buttocks and left
ischial tuberosity (hip), cleanse open areas with normal saline, cleanse intact skin with
[MEDICATION NAME] and skin cleanser, then rinse well, pat dry, apply [MEDICATION NAME] to
open areas, cover with meplix foam border dressing and sacral border dressing, wound
dressing to be changed every two days and as needed.
–Nursing staff to apply [MEDICATION NAME] protective ointment as needed to protect
surrounding skin.
Record review of the resident’s Quarterly MDS dated [DATE] showed the resident:
-Was not cognitively impaired and had a BIMs (Brief Interview for Mental Status) score of
15 and was able to make his/her own decisions.
-Had an ostomy.
-Required extensive staff assistance with toileting and cares.
-Had one unhealed stage 4 pressure ulcer.
-Had [DIAGNOSES REDACTED].
Record review of the resident’s Treatment Administration Record (TAR) for (MONTH) (YEAR)
showed: the resident wound on his/her coccyx/bilateral buttocks and on his/her left
ischial tuberosity:
-Was to clean the wounds with normal saline (NS) to the open area of the wounds.
-Cleanse the surrounding intact skin with [MEDICATION NAME] cleanser (Skin wound and
general skin cleanser, will help prevent cross-infection of dangerous staph infections)
and skin cleanser, then rinse and pat dry.
-Apply [MEDICATION NAME] wound dressing (a type of collagen dressing designed to kick
start the healing process while providing protection from infection) inside the wounds and
cover with boarder dressing and sacral boarder dressing.
-Change the resident’s dressing every two days and as needed, if the dressing was soiled
or had fallen off.
-Apply [MEDICATION NAME] protective ointment as needed to protect surrounding skin.
During an observation of the resident’s mechanical transfer on 9/28/18 at 10:00 A.M.,
showed:
-CNA/RA already in the resident’s room and CNA F enter the resident’s room and obtain pair
of gloves without washing his/her hands or using hand sanitizer.
– CNA/RA placed the sling under the resident on right side, then rolled the resident to
left side to remove the resident’s old brief, then position the shower sling (has hole to
wash bottom area.
-CNA’s did not change gloves or was theirs hands and continue to connect the sling to the
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265362

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

MEADOW VIEW OF HARRISONVILLE HEALTH & REHAB

STREET ADDRESS, CITY, STATE, ZIP

2203 EAST MECHANIC STREET
HARRISONVILLE, MO 64701

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0880

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 22)
Hoyer,
-Raised the resident up in the air and slowly moved to the shower chair.
-CNA/RA guided the resident while LPN A managed the Hoyer.
-The resident was transferred to the shower chair.
-Nursing Staff removed gloves before leaving the resident’s room and washed their hands
with soap and water.
During observation of the resident’s wound care on 09/28/18 at 11:05 A.M., showed:
-RN A and RA/CNA and CNA G was present in the resident room.
-The nursing staff did not wash his/her hand when enter the resident’s room.
-The RN A had setup a paper barrier for the resident’s wound care supplies.
-The RN A had used hand sanitizer for his/her hands then applied gloves and began wound
care for the resident.
-He/she had cleaned the resident’s wound on his/her coccyx/bilateral buttocks and then on
his/her left hip with normal saline soak gauze pad.
-He/she cleaned inside the wound of the coccyx first then with a new gauze wipe cleaned
around outside the resident’s coccyx wound, and then repeated the process for all three
wounds. RN A did not remove his/her gloves or washed or santitize his/her hands inbetween
each of the three wounds. After the last wound was cleaned RN A
-Removed his/her gloves and used hand sanitizer on his/her hands, and then placed new
gloves on his/her hands.
-RN A had cleaned the scissors and then cut the [MEDICATION NAME] dressing to fit each of
the three wounds and placed a piece of the [MEDICATION NAME] in each of the resident’s
wounds and he/she covered the resident’s wounds with two dressing.
-RN A had dated and initials the dressing.
-RN A removed his/her gloves and washed his/her hands.
During an interview on 9/28/18 at 11:16 A.M. RN A said:
-When he/she entered or exited the resident’s room he/she should either wash his/her hands
or use hand sanitizer.
-Before providing wound care should have washed his/her hands with soap and water then
applied a new pair of gloves.
-If the residents have more than one wound, should had treated each wound separately to
prevent cross contamination.
-He/she should have washed his/her hands between each wound.
-He/she said that he/she did not follow the resident’s physician order [REDACTED].
-Instead he/she had just used normal saline to clean the intact skin around the resident’s
wound.
-His/her plan was to redo the dressing change later today.
5. During observation of resident’s blood sugar monitoring on 9/28/18 at 7:26 A.M. with RN
B showed for Resident #34 and Resident #15:
-RN B entered the residents room and used hand sanitizer for his/her hands, then applied
gloves to his/her hands.
-Checked the resident’s blood sugar, for Resident #34, RN B had the same gloves on his/her
hands used to perform the resident’s blood sugar monitor and then gave the resident’s
his/her insulin per multi dose insulin pen with same gloves on his/her hands.
-Removed his/her gloves and washed his/her hands before exiting the resident room.
-RN B said each resident had their own glucometer in a black cloth case, then RN B had
taken the glucometer in the case into the resident’s room and placed onto the resident’s
bedside table without a barrier.
-After checking the resident’s blood sugar, he/she returned to the medication cart and
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265362

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

MEADOW VIEW OF HARRISONVILLE HEALTH & REHAB

STREET ADDRESS, CITY, STATE, ZIP

2203 EAST MECHANIC STREET
HARRISONVILLE, MO 64701

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0880

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 23)
without cleaning the glucometer machine and the outside of the glucometer case, had placed
each resident’s glucometer machine back into the medication cart drawer, next to the other
resident’s glucometer case.
During an interview on 9/28/18 at 7:51 P.M., RN B said:
-The residents each have their own glucometer and should be cleaned at least every shift.
-He/she should have had a barrier for the glucometer bag and should clean the outside with
bleach wipe afterwards.
6. During an infection Control interview on 10/02/18 at 2:38 P.M., LPN C /Unit Manager
said:
-The staff’s hands should be washed before and after providing care, when noticeably
soiled, before and after administering eye medication, peg tubes, and other treatments.
-Hand sanitizer can be used between residents when passing medication.
During an interview on 10/03/18 at 2:14 P.M., the DON said he/she expects nursing staff to
wash their hands or use hand sanitizer upon entering the resident’s room, before putting
on gloves, with each glove change, when going from dirty to clean processes, and before
leaving the room after removing gloves.

F 0923

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Have enough outside ventilation via a window or mechanical ventilation, or both.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation and interview, the facility failed to ensure there was negative air
flow in the following areas: the soiled linen side of the laundry area, the soiled utility
room located at the West nurse’s station, and resident rooms 211, 509, 508, 505, 504, 503,
502, 409, and 402. This practice potentially affected at least 13 residents who resided in
those rooms. The facility census was 66 residents.
**Note: Air flow was tested by holding one piece of tissue paper to the ceiling vent. If
the paper was sucked up then negative air flow was present; if the paper was not drawn to
the ceiling vent, then negative airflow was absent.
1. Observations with the Administrator, the Maintenance Director and the Housekeeping
Account Manager on 10/28/18, showed the absence of negative air flow from the following
areas:
– At 10:35 A.M., there was the absence of negative air flow from three ceiling vents on
the soiled linen side of the laundry;
– At 11:09 A.M., there was the absence of negative air flow within the soiled utility room
located at the West Nurse’s station;
– At 11:16 A.M., there was the absence of negative air flow from the restroom ceiling vent
in resident room [ROOM NUMBER];
– At 1:49 P.M., there was the absence of negative air flow from the restroom ceiling vent
in resident room [ROOM NUMBER];
– At 1:52 P.M., there was the absence of negative air flow from the restroom ceiling vent
in resident room [ROOM NUMBER];
– At 1:57 P.M., there was the absence of negative air flow from the restroom ceiling vent
in resident room [ROOM NUMBER];
– At 1:58 P.M., there was the absence of negative air flow from the restroom ceiling vent
in resident room [ROOM NUMBER];
– At 1:59 P.M., there was the absence of negative air flow from the restroom ceiling vent
in resident room [ROOM NUMBER];

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265362

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

MEADOW VIEW OF HARRISONVILLE HEALTH & REHAB

STREET ADDRESS, CITY, STATE, ZIP

2203 EAST MECHANIC STREET
HARRISONVILLE, MO 64701

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0923

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 24)
– At 2:02 P.M., there was the absence of negative air flow from the restroom ceiling vent
in resident room [ROOM NUMBER];
– At 2:14 P.M., there was the absence of negative air flow from the restroom ceiling vent
in resident room [ROOM NUMBER]; and
– At 2:16 P.M., there was the absence of negative air flow from the restroom ceiling vent
in resident room [ROOM NUMBER].
During an interview on 10/2/18 at 10:01 A.M., the Maintenance Director said they do not
let him/her know when there is the absence of negative air flow. There are work order
sheets at both nurse’s stations and they (the facility staff) should fill out the work
order sheets.

F 0925

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Many

Make sure there is a pest control program to prevent/deal with mice, insects, or other
pests.

Based on observation, interview and record review, the facility failed to maintain
openings in the attic area over the 600 Hall and the 100 Hall free of penetrations that
could let pests in; to maintain the soffit area at the back area close to the employee
smoking area free of an opening that wasps flew in and out of; and to maintain the wall
under the three compartment sink in the kitchen and the wooden shelf above the food
processor area in the kitchen, free of openings where insects could harbor. This practice
potentially affected an unknown number of residents. The facility census was 66 residents.
1. Observation with the Maintenance Director on 9/27/18, showed the following:
– At 11:01 A.M., a 9 inch (in.) long by 9.75 in. wide hole, was present on the outside
wall of the 600 Hall attic area that could let pests in;
– At 11:04 A.M., an opening (that opening was out of reach for measurement), was present
on the outside wall of the 100 Hall with grass clippings present that could let pests in;
– At 12:43 P.M., a 19 in. long by 4.5 in wide opening was present in the soffit along the
back wall of the facility close to the employee smoking area, with wasps flying in and out
of that opening; and
– At 12:45 P.M., the Maintenance Director said he/she was unaware of that opening on the
soffit.
2. Observation with the Maintenance Director and the Housekeeping Account Manager on
9/28/18 at 12:58 P.M., showed one roach crawled on the wall of the dry goods storage room.
3. Observation during the lunch meal preparation on 10/1/18, showed the following:
– At 9:54 A.M. a roach crawled on the wall under the three compartment sink and there was
an area within the wall where several other roaches were present as evidenced by antennae
oscillating;
– At 9:56 A.M., the Dietary Manager (DM) said he/she would have to have a conversation
with the Maintenance Director about getting that area of the wall fixed;
– At 9:59 A.M., the DM said he/she saw insects in the past but they (the dietary staff)
would call the local pest control company, that company would come out and spray, but they
did not know about that area in the wall; and
– At 10:08 A.M., roaches crawled on the wooden shelf and another roach was observed hiding
inside a hole in that wooden plank above the iced tea maker and where the first aid kit
was stored.
Record review of the 2009 Food and Drug Administration Food Code, showed the following:

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265362

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

MEADOW VIEW OF HARRISONVILLE HEALTH & REHAB

STREET ADDRESS, CITY, STATE, ZIP

2203 EAST MECHANIC STREET
HARRISONVILLE, MO 64701

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0925

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Many

(continued… from page 25)
Chapter 6-501.111 Controlling Pests.
The premises shall be maintained free of insects, rodents, and other pests. The presence
of insects, rodents, and other pests shall be controlled to eliminate their presence on
the premises by:
A) Routinely inspecting incoming shipments of food and supplies;
B) Routinely inspecting the premises for evidence of pests;
C) Using methods, if pests are found, such as trapping devices or other means of pest
control as specified under; and
D) Eliminating harborage conditions.
6-501.112 Removing Dead or Trapped Birds, Insects, Rodents, and Other Pests.
Dead or trapped birds, insects, rodents, and other pests shall be removed from control
devices and the premises at a frequency that prevents their accumulation, decomposition,
or the attraction of pests.