Grandview Healthcare: 11-Day Constipation Crisis - MO
Federal inspectors found that Grandview Healthcare Center staff ignored basic monitoring requirements for residents at risk of severe constipation, despite having detailed physician orders for multiple treatments.
The most severe case involved a resident who had no documented bowel movements from July 22 through August 2. Staff were taking multiple medications known to cause constipation, including antidepressants and anti-nausea drugs. The resident's care plan specifically directed staff to monitor bowel movements every shift and report any absence lasting two days to nurses.
Nobody reported anything.
RN A told inspectors on August 29 that staff notified him at 8 a.m. on August 1 about the resident's change in condition. "He/She said no one notified him/her the resident had not had a bowel movement since 07/24/25," inspectors wrote.
The resident's eating was declining, the nurse said, "but so was everything else, and had been."
Medical records revealed the scope of staff failures. The resident had physician orders for three different constipation medications: Bisacodyl suppositories, Milk of Magnesia, and Miralax, all available as needed. Medication administration records showed none of these treatments were given throughout July, despite the resident going days without bowel movements.
The resident was also taking Celexa, an antidepressant that commonly causes constipation, along with Famotidine and Ondansetron, both medications that can worsen the condition.
CNA F, responsible for documenting bowel movements, told inspectors during an August 29 interview that certified nursing assistants are supposed to notify the charge nurse if a resident hasn't had a bowel movement in three days. "He/She said he/she did not know the resident had not had a bowel movement since 07/24/25, and staff did not report to him/her the resident was constipated."
A second resident also experienced extended periods without documented bowel movements. Records showed gaps from July 4 to July 11 (seven days) and July 13 to July 21 (eight days), with no evidence that staff administered ordered constipation medications during these periods.
Licensed Practical Nurse B explained the monitoring system to inspectors on August 25. CNAs should document bowel movements each shift, with licensed staff checking for residents who haven't had movements for three days. "If a resident does not have a bowel movement for three days, licensed staff should administer as needed medications for constipation," the nurse said.
The nurse added that if staff don't document monitoring, "then he/she would think staff did not monitor the resident's bowel movements."
The facility's administrator acknowledged the failures during a September 5 interview, saying he didn't know why staff failed to document bowel movements for either resident. The administrator explained that both Certified Medication Technicians and licensed staff should monitor residents and administer constipation medications if someone hasn't had a bowel movement in two days.
CMT D confirmed the protocol during the same day's interview, stating that aides document daily bowel movements while licensed staff monitor patterns and notify medication technicians when treatment is needed.
The administrator revealed that the facility had recently implemented new documentation requirements after recognizing the monitoring failures. About two weeks before the inspection, the MDS Coordinator trained staff on updated electronic medical record procedures that would prevent staff from documenting other care until they first recorded whether residents had bowel movements.
Both affected residents had care plans dating from July 23 that identified them as at risk for constipation and dehydration. The quarterly MDS assessment from August 13 classified one resident as occasionally incontinent of bowels, and physician orders from July included a formal diagnosis of constipation.
Federal inspectors classified the violations as causing actual harm to few residents. The inspection stemmed from a complaint filed under case number 2590452.
The facility's systematic failure to follow its own constipation monitoring protocols left vulnerable residents without basic medical interventions for extended periods, despite having detailed physician orders and care plans specifically designed to prevent such complications.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Grandview Healthcare Center from 2025-09-05 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
GRANDVIEW HEALTHCARE CENTER in WASHINGTON, MO was cited for violations during a health inspection on September 5, 2025.
The most severe case involved a resident who had no documented bowel movements from July 22 through August 2.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.