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Editor’s note: A previous version of this story indicated that Garden Valley Rehabilitation Center is no longer allowed to take new patients. That statement was in error, and we regret the mistake. The story has been corrected.  

KANSAS CITY, Mo. — Bed sores, missed medications and the overwhelming smell of urine as soon as you walk inside. That’s how a visiting nurse described conditions at a local nursing home.

It was so bad she reported the facility to the state.

“I would tell them — and I mean this from all I have and the core of my soul — take your family out of that facility and run,” Terracita Lowery said.

Lowery, a registered nurse, has spent 23 years working in nursing homes across the country. She said she’s never seen one as bad as Garden Valley Rehabilitation Center on Granby Road in Kansas City’s Northland.

In the two days she worked there before quitting in disgust, she said the problems were overwhelming.

Patient medications were either missed or given out incorrectly, bed sores were common, call lights weren’t answered and, she said, about half the staff weren’t wearing face masks.

Last month, Garden Valley reported more than 40 cases of COVID-19.

“In my 23 years of nursing I have never spoken to the media … but this is my last time allowing something like this because this is the worst I’ve seen,” she said. “And I say my God I serve would not be happy with me if I did not speak because that is someone’s mother, father, brother, sister you name it.”

Before she left shortly after Thanksgiving, she took a photo of a certified nursing assistant asleep at the front desk. She said that was typical for that employee and complaints to management didn’t make a difference.

Missouri officials are aware of this nursing home. An inspection last February found violations at a rate four times higher than in the average nursing home. At least 75 patients still live there.

Darlynn Thompson’s brother used to be one of them. From the beginning, she said, there were problems.

“He called me bright and early on a Saturday morning,” she recalled. He told her, “‘I didn’t want to say anything because you told me to give it a chance, but I haven’t had a shower in two weeks.'” 

Her brother Sinclair Thompson had moved to Garden Valley in August. Every time he called to let her know there were problems, she called the front desk for help. Most of the time, she said, no one answered. Because of COVID-19 restrictions, she wasn’t allowed to visit.

Then, in October, her brother called to say he had the virus. A few days later, his roommate called her, saying her brother could barely breathe and the oxygen machine they had given him appeared to be broken.

“I said, ‘I’m calling 911,'” Darlynn said.

An ambulance took her brother to the hospital where he spent five days battling pneumonia. He survived and is now living in a new facility.

Others weren’t so fortunate. One woman died of sepsis in 2018 just two weeks after entering Garden Valley for rehabilitation from surgery for a broken hip.

Her granddaughter told FOX4 that what started as a small bed sore became a gaping wound, so large you could put a fist into it.

“Within 16 days of being admitted into their facility, she died,” said the granddaughter who asked not to be identified. “It was terrible. I hope and pray she didn’t really know what was going on.”

For more than three months, Garden Valley has been on a federal list of troubled nursing homes. Homes on that list are supposed to receive greater oversight.

Garden Valley Rehab is owned by CommuniCare. We asked CommuniCare about the multiple allegations Lowery and relatives of former patients made.

CommuniCare said it doesn’t comment on anything regarding specific patients, but said that its staff was dedicated and had put in great efforts battling the pandemic and protecting residents. Here is part of its statement:

“Recently, Garden Valley and CommuniCare voluntarily took the initiative to develop and implement a Plan of Correction to improve quality of care during this unprecedented pandemic, including:

  • Downsizing the building to improve staff-to-resident ratio
  • Adding Supervisors
  • Increasing clinical oversight

The facility continues to follow the health protocols issued by federal and state health officials.”

Complaints about Garden Valley date back years. Shelley Armato contacted FOX4 Problem Solvers after taking her father there in 2017 when he was in the final stages of cancer. Back then, Garden Valley was owned by a different company.

Armato said as soon as she stepped inside, she was appalled.

“The place stunk,” she said. “It was just human stench. The room was dirty.”

She removed her father the next day and reported Garden Valley to the state. She said no one from the state ever contacted her, which is why, in part, she was relieved to talk to FOX4 Problem Solvers.

“Somebody has to do something because this is not OK,” she said.

Since COVID-19 hit, barring families from visiting nursing homes, conditions for those living inside have gotten worse, said attorney Rachel Stahle. She’s sued multiple facilities for abuse and neglect, including Garden Valley.

“We are getting all sorts of calls regarding pressure ulcers or bed sores because these people are not getting turned, they are not getting up … they are not getting changed,” she said. “They are not getting to the bathroom.

“In a place like Garden Valley, where we know there are already concerns, we are getting even more calls on places like that now.”

The Missouri Department of Health and Senior Services, which regulates nursing homes, never responded to our questions as to why Garden Valley is allowed to continue to care for the elderly despite a multitude of violations.

Garden Valley says that the state has approved it’s plan to correct problems at the nursing home. Therefore, according to Garden Valley, the state has no intention of shutting down the nursing home.

Lowery said the system isn’t working, and the elderly are paying the price.