Below average — CMS composite of the measures below.
A standard survey is most likely before around September 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Maryville Living Center during CMS and state inspections, most recent first.
A resident with significant cognitive loss and a history of behavioral problems, including self-harm gestures, aggression toward others, and destructive acts, was hospitalized after escalating violent behaviors. The facility then initiated an emergency discharge and refused to allow the resident to return, but the transfer/discharge form in the record was incomplete and the administrator stated there was no transfer and discharge policy.
A resident with cognitive impairment, stroke-related weakness, and mobility issues fell while attempting to get into bed and was returned to bed with a mechanical lift, but no thorough post-fall assessment was documented and the fall was not added to the care plan. Over the next several days, CNAs and therapy staff observed non-verbal signs of pain and leg swelling, and the family reported hip/leg pain, yet nursing documentation showed incomplete assessments, pain scores of 0, and no administration of ordered PRN acetaminophen. A mobile x-ray was ordered but delayed, and the resident was not sent to the hospital when the x-ray could not be obtained as planned; when imaging was finally completed, it revealed an acute right hip fracture, confirming that the facility failed to provide timely follow-up care and pain management after the fall.
A resident with atrial fibrillation, vertigo, and moderate cognitive decline reported having a large amount of cash upon admission. The SSD and a charge nurse counted over $2,000, after which the SSD secured most of the cash, along with a checkbook and bank cards, in an unsecured box in an office desk drawer and locked only the office door. By the next day, when the SSD went to retrieve the funds for the family, $600 in cash was missing, although the checkbook and bank cards remained. The facility’s investigation found that the desk drawer and box did not lock, the emergency key box for room keys in the medication room was found unlocked, and multiple staff had potential access to the SSD office key. A grievance was filed on behalf of the resident for the missing $600, and the resident was not reimbursed until weeks later.
A resident with severe cognitive impairment and total dependence for transfers was injured when a staff member failed to follow the care plan, using a gait belt instead of a mechanical lift with two staff as required. The improper transfer led to the resident being lowered to the floor and later diagnosed with a right lower leg fracture. Staff interviews confirmed that the correct procedures were not followed and that the aide did not check the care plan prior to the transfer.
A resident with dementia and impaired vision was served hot coffee by an LPN from an unauthorized coffee pot without a temperature check, in violation of facility policy. The resident, left unsupervised, spilled the coffee and sustained burns to the chest and abdomen, requiring wound care and additional medical treatment.
Two residents with cognitive impairment were subjected to physical abuse by another resident with a history of escalating behavioral issues, including hair pulling and being struck with a water pitcher, resulting in physical injury and distress. Staff and medical records confirmed the aggressive resident's ongoing agitation and prior incidents, but the facility did not prevent repeated access and harm to other residents.
Several staff members took unauthorized photos and a video of four residents, most with dementia, and shared them in a group chat on social media, including images with demeaning captions. The residents were unaware of being recorded, and staff violated facility policies on privacy, abuse prevention, and use of personal devices, despite having received relevant training.
A resident with dementia was hit by a CMT in the face during an incident in the SCU. Despite facility policy, the CMT remained in contact with the resident for over 2.5 hours before being removed. Staff interviews revealed confusion about reporting procedures, contributing to the delay in addressing the abuse.
The facility failed to maintain a sanitary kitchen, with unclean surfaces, improper food storage, and incomplete cleaning logs. Food temperatures were not consistently checked, and sanitation procedures were not followed, including improper handwashing and lack of sanitizer use. The facility also lacked a policy for dating and labeling foods, leading to undated items in storage.
The facility failed to respect the rights of six residents by not providing adequate grooming and privacy. Three residents were not groomed properly, with facial hair not being shaved regularly despite their preferences and needs. Additionally, the facility did not respect the privacy of three residents, with personal care instructions being visible to others and blood sugar checks being conducted in the hallway.
The facility failed to honor the choice of two residents regarding their wake-up times, as care plans did not specify their preferences. One resident with cognitive impairment was left waiting in a wheelchair despite expressing a desire to lay down, while another resident with severe cognitive impairment and pressure ulcers was not consulted about their schedule. Staff interviews revealed a lack of communication and documentation regarding residents' preferences, leading to a deficiency in honoring their rights.
The facility failed to address grievances and recommendations from the resident council, affecting all residents involved. Residents were unaware of the grievance process and expressed concerns about care issues like cold food and long call light response times. The facility did not document attempts to resolve these concerns, and staff interviews revealed inconsistencies in the grievance process.
The facility failed to inform residents about the grievance process, resulting in unaddressed concerns about food quality, call light response times, and bathing schedules. Residents were unaware of how to file grievances, and staff interviews revealed inconsistent knowledge and follow-up on grievances. A family member reported a lack of follow-up on grievances, and grievance reports lacked documentation of resolution or notification to complainants.
The facility failed to create individualized care plans for two residents, neglecting to address dehydration, falls, and code status. One resident, with a history of falls and dehydration, lacked specific interventions in their care plan despite recent incidents. Another resident's care plan did not reflect their DNR status. Staff interviews confirmed these issues should have been care planned.
The facility failed to administer medications within the appropriate time frame for three residents. A resident received Levothyroxine late due to staff cleaning delays, while another resident's multiple medications, including Levothyroxine and Ropinole, were administered late. Additionally, a third resident's Gabapentin was given past the scheduled time. The DON acknowledged the delays, noting that medications should be administered within one hour of their scheduled time.
The facility failed to provide necessary assistance with ADLs, affecting four residents. Two residents did not receive regular showers, and two others did not receive complete incontinence care. Observations showed residents with unkempt appearances and improper cleaning techniques by staff. Interviews revealed insufficient staffing and lack of dedicated shower aides.
The facility failed to ensure residents were free from accident hazards and provided with adequate supervision. A resident was not served the correct therapeutic diet, another had medication left unattended, and improper techniques were used during a sit-to-stand lift transfer, causing discomfort and potential risk of injury.
The facility experienced significant staffing shortages, leading to multiple deficiencies in resident care. A resident with severe cognitive and mobility impairments did not receive regular showers, and meal services were consistently delayed, affecting all residents. Medications were administered late, and the Activity Director was often pulled to cover staffing gaps, resulting in canceled activities. The facility lacked policies for staffing and showers, contributing to these issues.
The facility had a medication error rate of 32.14%, with staff failing to follow manufacturer guidelines for insulin administration, not removing a Lidocaine patch on time, and improperly crushing medications. Additionally, eye drop administration did not adhere to policy, affecting multiple residents.
The facility failed to secure medication carts, leaving them unlocked and unattended, and did not properly manage medications for a resident with severe cognitive impairment. Additionally, an expired Influenza Vaccine was not discarded, and a Lactulose Solution lacked a pharmacy label. These deficiencies were observed despite existing policies requiring secure storage and proper labeling of medications.
The facility failed to provide adequate dietary staffing, resulting in delayed meal service and unsanitary kitchen conditions. Observations showed meals were served late, and the kitchen was unclean with incomplete cleaning logs. Staff reported high turnover and insufficient training, contributing to the issues.
The facility failed to serve food at safe and appetizing temperatures, as observed in a sample of residents. Hot foods were served below the required 120 degrees Fahrenheit, with items like fish and carrots falling short. Residents reported dissatisfaction with food temperatures and quality, noting cold hot foods and unappetizing meal appearances. Despite expectations from dietary staff to maintain proper temperatures, these were not met, resulting in the deficiency.
Two residents in a facility were found with inaccessible call lights, despite their care plans and staff expectations. One resident, with severe cognitive impairment and mobility issues, had the call light out of reach, requiring family intervention. Another resident, with dementia and impaired vision, was observed multiple times with the call light on the floor or hanging out of reach, necessitating leaving the bed to seek help. Staff interviews confirmed the expectation for call lights to be within reach, highlighting a failure to meet this standard.
A facility failed to protect residents' privacy when an LPN left a medication cart computer screen unattended and visible with resident information accessible. This occurred multiple times, with the screen left open in public areas. Interviews confirmed that staff were expected to lock or shut down screens when unattended, as per facility policy.
A resident with a left hip fracture and dementia developed a Stage II pressure ulcer on the left heel, which was not identified by the facility staff until discovered by the family. The facility failed to conduct timely skin assessments and implement preventive measures, despite the resident being bedridden and requiring assistance for transfers. Interviews confirmed that the resident was not admitted with the ulcer, and weekly skin assessments were not completed as required.
The facility failed to serve meals according to residents' dietary needs, with staff not following recipes or using correct portion sizes. Observations showed inconsistent meal preparation, with incorrect ingredients and serving utensils used. Interviews revealed staff did not adhere to menu guidelines, leading to potential nutritional deficiencies for all residents.
A resident with dementia and malnutrition was served food inconsistent with their dietary orders, receiving regular bacon and scrambled eggs instead of the prescribed minced and moist diet. Despite staff awareness and in-service education, incorrect diets were an ongoing issue, with the dietary manager acknowledging the problem and emphasizing the importance of following physician-ordered diets to prevent choking.
A resident with severe cognitive impairment and multiple care needs was not provided care in a manner that prevented infection, as staff failed to wash hands between dirty and clean tasks. Observations showed that a CNA, LPN, CMT, and NA did not adhere to hand hygiene protocols during care, despite the resident being on enhanced barrier precautions. Interviews revealed inconsistencies in staff understanding and implementation of handwashing practices.
Incomplete discharge process for a resident with severe behavioral issues
Penalty
Summary
The facility failed to provide an appropriate discharge for one resident when it refused to allow the resident to return after hospitalization based on behaviors that occurred before the hospitalization. The resident had a BIMS score of 3, indicating significant cognitive loss, and diagnoses included stroke, high blood pressure, vision loss, amnesia, and brain damage. The care plan documented behavior problems, including wrapping the call light around the neck, shoulder bumping another resident, destructive behaviors such as kicking another resident's TV and tearing trim from the wall/window, standing on the air conditioning unit, hallucinations at times, and placement on 15-minute checks. Nurse progress notes showed the resident returned from the hospital with no behaviors and orders for hydroxyzine IM as needed for agitation and behaviors, but later became increasingly agitated, repeatedly asked staff to kill him/her, asked staff to hit him/her with a broom handle, pulled a light fixture out of the wall, pulled screens from windows, attempted to punch out windows, and was placed on 1:1 observation. The resident was later sent to the emergency room for increased behaviors and then admitted to the hospital for increased violent behaviors. The facility's Notice of Transfer/Discharge form in the record was incomplete, with no resident name, facility name, administrator, business office manager, phone number, resident representative, address, date of transfer, or transfer location, and the administrator stated the resident was an emergency discharge because he/she was a danger to other residents and that there was no transfer and discharge policy.
Failure to Timely Assess, Manage Pain, and Obtain Evaluation After Resident Fall With Hip Fracture
Penalty
Summary
The deficiency involves the facility’s failure to provide timely follow-up care, assessment, and pain management after a resident sustained a fall and subsequently was found to have a right hip fracture. The resident had significant cognitive deficits, stroke with right-sided weakness, COPD, and TIA, and was dependent on staff for toileting and bathing. The care plan identified the resident as at risk for falls with walking and balance problems and specified that the resident should not be left alone in the wheelchair or bathroom and should have the call light within reach, but the fall that occurred on 02/10/26 and the resident’s pain were not added to the care plan. After the fall, documentation showed the resident was found on the floor near the bed after attempting to get into bed and was transferred back to bed with a mechanical lift. Following the fall, there was no documented post-fall assessment on the day of the incident, and subsequent nursing notes did not include complete assessments of gait, grasp, or upper and lower extremity movement. CNA and therapy staff reported the resident was grunting, groaning, grimacing, and turning red with movement, and that the leg appeared swollen, but these observations were not reflected in the nursing documentation. Pain assessments recorded on the MAR for several days after the fall consistently showed a pain score of 0 on all shifts, and no acetaminophen or other pain medication was administered, despite family reports of pain and therapy staff concerns. The facility’s policies required assessment and treatment of injuries after a fall, notification of the practitioner for accidents or new pain, and support of residents’ right to optimal pain assessment and management, including recognition of non-verbal expressions of pain. When the resident’s family reported pain in the right leg/hip area, an order was obtained for a mobile x-ray of the right hip. The mobile x-ray service was unable to perform the x-ray as initially scheduled and delayed it until the following day, yet the resident was not sent to the hospital that night despite ongoing pain complaints. Nursing notes during this period still lacked complete assessments of lower extremity movement. The x-ray ultimately showed an acute right hip fracture, and the resident was then sent to the hospital by ambulance. Interviews with staff revealed that therapy had notified an LPN about the resident’s pain and that multiple CNAs had reported pain complaints after the fall, but nursing staff did not treat the pain or promptly arrange hospital evaluation when mobile x-ray was unavailable, resulting in several days without appropriate pain management or timely diagnostic follow-up.
Failure to Safeguard Resident Funds Resulting in Missing Cash
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident’s money from misappropriation after it was placed under the facility’s control. A resident with atrial fibrillation, vertigo, and moderate cognitive decline (BIMS score of 8) was admitted and reported having cash in a purse. The Social Services Designee (SSD) and a charge nurse counted $2,137 in cash, along with a checkbook and three bank cards. The resident chose to keep $20, and the SSD took the remaining $2,117 in cash, plus the checkbook and bank cards, and placed them in a box in a desk drawer in the SSD office. The SSD documented the amount in a progress note and notified the resident’s family to pick up the money and valuables. The SSD reported that the box used for storage was in a desk drawer and that neither the box nor the drawer locked. After placing the money and valuables in the box, the SSD left for the day, locking only the SSD office door. The next day, the SSD returned to work, was in and out of the office, and later went to retrieve the money to give to the resident’s family. At that time, the SSD observed that the cash was not in the same position as previously placed, and upon recounting, discovered that $600 was missing, leaving $1,517. The checkbook and bank cards remained in the box. The SSD confirmed that the Administrator and DON had keys to the SSD office and that an additional SSD office key was kept in an emergency key box in the medication room, to which nurses and certified medication technicians had access. The facility’s own investigation documented that the safe box and desk drawer in the SSD office did not lock and that the emergency key box in the medication room was found unlocked, with the zip lock seal missing, while the SSD key was still present inside. Staff working during the relevant time frame were interviewed and denied knowledge of the missing money or accessing the SSD office. A grievance was filed on behalf of the resident stating that $600 went missing while being held in the SSD office. Law enforcement was notified and obtained details from the Administrator and SSD about how the money was acquired, stored, and later found to be short. The facility did not reimburse the resident for the missing $600 until several weeks after the incident, despite the money having gone missing while in the facility’s custody and control.
Failure to Follow Care Plan During Transfer Results in Resident Fracture
Penalty
Summary
A deficiency occurred when facility staff failed to follow a resident's care plan during a transfer, resulting in the resident sustaining a right lower leg fracture. The resident, who had severe cognitive impairment and was dependent on staff for all transfers and activities of daily living, was care planned to require a mechanical lift with the assistance of two staff members for all transfers. Despite this, a nursing aide attempted to transfer the resident using only a gait belt and without the required mechanical lift or a second staff member present. The aide was not aware of the resident's transfer requirements and did not check the care plan prior to the transfer, stating that they did not have time to look up the information. During the transfer, the aide was unable to safely move the resident and had to lower them to the floor. At the time, no immediate signs of injury were noted, and the resident was assisted back to bed. However, the following morning, the resident was found to have swelling, bruising, and pain in the right ankle, which was subsequently diagnosed as a fracture of the distal tibia and fibula. The resident's care plan and facility policy both clearly indicated the need for mechanical lift transfers with two staff, and this information was accessible in the electronic medical record and care plan documentation. Interviews with staff revealed that the majority were aware of the proper procedures for transferring residents who require mechanical lifts, including the need for two staff members and the prohibition of using gait belts for such residents. The aide involved in the incident admitted to not checking the care plan and not being familiar with the resident's specific needs. Other staff present at the time confirmed that the correct transfer method was not used, and that the aide had been advised to use the mechanical lift but did not comply.
Failure to Follow Hot Beverage Policy Results in Resident Burns
Penalty
Summary
A deficiency occurred when the facility failed to ensure a safe environment and adequate supervision for a resident with moderate cognitive impairment, dementia, impaired vision, and a need for assistance with activities of daily living. The facility's hot beverage policy required that coffee and hot water be cooled to 130 degrees before serving to residents, and that only dietary staff provide hot beverages after checking the temperature. However, a staff member brought a personal coffee pot to the nursing station, and an LPN served hot coffee to the resident without checking its temperature, in violation of the policy. The resident, who had diagnoses including dementia, seizure disorder, and anxiety, requested coffee and a snack. The LPN provided the coffee, which the resident subsequently spilled on their chest and abdomen while unsupervised. The incident resulted in burns, with progress notes documenting reddened areas, blisters, and wounds to the chest and abdomen. The resident required wound care, including cleansing, application of antibiotic ointment, and dressings, as well as additional supplements and medications as ordered by the provider. Interviews and record reviews confirmed that the coffee pot was not authorized, the temperature of the coffee was not checked, and the resident was left unsupervised. Staff interviews revealed that the hot liquid policy was in place prior to the incident, but not followed. The resident's care plan and medical records indicated a need for supervision and assistance, which was not provided at the time of the incident, directly leading to the resident's injury.
Failure to Protect Residents from Physical Abuse by Another Resident
Penalty
Summary
The facility failed to protect two residents on the Memory Care Unit from physical abuse by another resident. One resident, who had moderate cognitive loss and a history of verbal and physical behaviors, became increasingly agitated and aggressive over a period of weeks. This resident pulled another resident's hair and later struck a different resident, who was also the spouse, with a full water pitcher, causing physical injury and mental distress. Staff interviews and medical record reviews confirmed that the aggressive resident had exhibited escalating behaviors, including yelling at staff, throwing objects, and physical altercations with other residents. The first incident occurred when a resident with extensive cognitive loss and no prior behavioral issues was walking out of the dining room and interacted with the aggressive resident's spouse. The aggressive resident responded by yanking the other resident's hair and pulling them down. The second incident involved the aggressive resident entering the spouse's room and striking them in the head with a water pitcher, resulting in abrasions and redness. Staff members heard distress sounds and intervened, but not before the aggressive resident made contact multiple times. The spouse was found in a defensive posture, and the aggressive resident was removed from the room. Medical records and staff interviews indicated that the aggressive resident had a documented history of behavioral problems, including physical aggression toward staff and other residents, and had been seen by psychiatric professionals for increased agitation. Despite these known risks, the resident was able to access and harm other residents on multiple occasions. The facility's failure to prevent these incidents resulted in physical and psychological harm to the affected residents.
Staff Shared Unauthorized Resident Photos and Videos on Social Media
Penalty
Summary
The facility failed to protect four residents from abuse when three staff members took unauthorized photos and one staff member took a video of the residents and posted them to social media. Two of the images included demeaning comments about the residents. The residents involved had varying degrees of cognitive impairment, with three diagnosed with dementia and some unable to understand or consent to being photographed or recorded. All four residents were unaware that their images had been captured or shared online. The staff involved used a Snapchat group chat to share these images and videos among themselves. The group included five nurse aides, and the content was shared without the knowledge or consent of the residents or their legal representatives. In some cases, the residents were depicted in vulnerable situations, such as wearing only a hospital gown or being the subject of derogatory captions. The facility's policies explicitly prohibited the use of personal devices to take photos or videos of residents and required staff to respect residents' privacy and dignity at all times. Interviews and record reviews confirmed that the staff had received training on abuse prevention, HIPAA, and the facility's cell phone and social media policies. Despite this, the staff members involved knowingly violated these policies. Some staff admitted to recognizing the actions as violations but failed to report them promptly. The incident was eventually reported by one staff member, leading to an internal investigation. The residents' cognitive limitations and inability to provide informed consent were significant factors in the deficiency, as was the staff's disregard for established protocols regarding resident privacy and abuse prevention.
Failure to Protect Resident from Abuse and Delay in Reporting
Penalty
Summary
The facility failed to protect a resident from abuse when a Certified Medication Technician (CMT) hit the resident in the face with an open hand. This incident occurred in the Special Care Unit (SCU) and involved a resident with significant cognitive loss, dementia with psychosis, and other conditions that required moderate assistance for activities of daily living. The resident was found on the floor by the CMT, and during the process of assisting the resident back to bed, the CMT reacted by smacking the resident across the face when the resident was swinging arms and kicking. Despite the facility's policy that mandates immediate removal of any alleged perpetrator from resident contact, the CMT remained in direct contact with the resident for over 2.5 hours after the incident. The incident was not reported to the Charge Nurse until nearly two hours later, and the CMT was not removed from the facility until the MDS Coordinator arrived and found the CMT still in the resident's room. The MDS Coordinator admitted to not instructing the Charge Nurse to remove the CMT from resident care, which was a mistake. Interviews with staff revealed a lack of clarity and training on reporting procedures for abuse. Both the Nurse Aide and Certified Nurse Aide involved in the incident were unsure of the proper steps to take and who to report the abuse to. The Director of Nursing and the Administrator were not informed of the incident until later, and the Administrator was unaware that the CMT had remained in contact with the resident until arriving at work. The facility's failure to immediately remove the CMT from resident contact and the delay in reporting the incident contributed to the deficiency.
Sanitation and Food Safety Deficiencies in Kitchen
Penalty
Summary
The facility failed to maintain a clean and sanitary kitchen environment, as observed by surveyors. The kitchen was found to have unclean surfaces, including tables that had not been cleaned after breakfast, a trash can lid with food residue, and a stove top with burnt food residue. Additionally, the steam table contained food particles, and the microwave was not clean. The dry storage room had spilled food items, and the walk-in cooler had eggs stored directly on the floor. The kitchen floors were littered with food particles, and there were no paper towels available at the handwashing sink. The facility's cleaning logs were incomplete, with no entries for several days, and the monthly cleaning schedule had no entries at all. The facility also failed to adhere to proper food temperature protocols. Staff did not take food temperatures on the steam table before service, and foods were not reheated to safe temperatures before serving. Observations showed that chicken fritters, minced meat, and macaroni were added to the steam table without temperature checks. Baked beans were reheated in the microwave but not temperature checked before being added to the steam table. The dietary manager and staff did not consistently document food temperatures, and some foods were not held at appropriate temperatures during meal service. Furthermore, the facility did not follow proper sanitation procedures. Clean cups were stored upright, and there was no thermometer in the refrigerator unit. The three-compartment sink was not properly sanitized, with test strips showing 0 parts per million of sanitizing solution. Staff did not wash their hands after contamination, and there were no sanitizer buckets prepared in the kitchen. The facility lacked a policy for dating and labeling foods, resulting in undated and unlabeled food items in storage. Staff also failed to wash hands between handling dirty and clean dishes, and there were no paper towels available for handwashing.
Deficiencies in Resident Grooming and Privacy
Penalty
Summary
The facility failed to respect the rights of six residents by not providing adequate grooming and privacy. Three residents were not groomed properly, with facial hair not being shaved regularly despite their preferences and needs. For instance, one resident with severe cognitive impairment was observed with facial hair on their chin, which was not consistently shaved during shower opportunities. Another resident, who was also severely cognitively impaired, expressed discomfort with their facial hair, yet it was not addressed by the staff. Additionally, the facility did not respect the privacy of three residents. One resident had their blood sugar checked in the hallway, which is against the facility's protocol. Another resident had a sign on their bathroom door detailing personal care instructions, including their name, which was visible to anyone entering the room. Similarly, another resident had multiple signs in their room detailing their care instructions, which were visible to other residents and visitors. Interviews with staff, including the Assistant Director of Nursing and the Director of Nursing, revealed that the facility's expectations were not met in these instances. Staff acknowledged that residents should be groomed regularly and that personal care instructions should not be visible to others. The facility also lacked a dignity policy, which contributed to these deficiencies in respecting resident rights.
Failure to Honor Resident Choice in Wake-Up Times
Penalty
Summary
The facility failed to ensure that residents were offered a choice of when they would like to get up in the morning, affecting two residents. Resident #30, who had moderate cognitive impairment and required substantial assistance, was observed sitting in a wheelchair at the nurse's station early in the morning, expressing a desire to lay down. Despite the resident's repeated requests, no staff responded promptly. Interviews revealed that staff were unaware of the resident's preferences, and the care plan did not specify the resident's desired wake-up time. Resident #43, with severe cognitive impairment and a history of pressure ulcers, was also affected. The resident was dressed and seated in a wheelchair at the nurse's station early in the morning. The care plan did not address the resident's preferred wake-up time, and the staff generally aimed to have residents up by 7:00 A.M. Interviews indicated that the resident's family was not consulted about their preferences, and the care plan lacked specific instructions regarding the resident's schedule. Interviews with staff, including the DON and ADON, highlighted a lack of communication and documentation regarding residents' preferences for wake-up times. The facility's policy emphasized resident self-determination, but the care plans did not reflect this, leading to a deficiency in honoring residents' rights to choose their daily schedules.
Failure to Address Resident Council Grievances
Penalty
Summary
The facility failed to honor the residents' right to organize and participate in resident/family groups by not adequately addressing grievances and recommendations made by the resident council. The facility did not maintain documentation of resident concerns, attempts to resolve these concerns, or follow-up actions. This affected all residents serving on the resident council and potentially other residents in the facility. During interviews, residents expressed that they were unaware of how to complete a grievance, did not have access to grievance forms, and did not know who the grievance officer was. They also raised concerns about showers not being given, tough meat, cold food, and long wait times for call lights, which resulted in incontinence and feelings of humiliation. The review of resident council minutes from April to June 2024 showed repeated concerns about food quality, call light response times, and other issues, with no documentation on how or if these concerns were addressed. Interviews with facility staff, including the Social Services Designee, Certified Nurse Aide, Administrator, and Director of Nursing, revealed inconsistencies in the grievance process and a lack of awareness among staff about the procedure. The Social Services Designee mentioned that grievances were located by the front door and that they would fill out grievances for residents if requested. However, there was no evidence that grievances were discussed in resident council meetings, and the facility's policy and goal to resolve issues within five days were not documented as being met.
Failure to Inform and Resolve Resident Grievances
Penalty
Summary
The facility failed to adequately inform residents about the grievance process, resulting in residents being unaware of how to file grievances or complaints. During a group interview, residents expressed that they did not know how to complete a grievance, lacked access to grievance forms, and were unaware of the grievance officer's identity or where to submit a grievance form. Additionally, concerns raised in resident council meetings, such as issues with food quality, call light response times, and bathing schedules, were repeatedly voiced over several months without resolution or follow-up. The facility's grievance policy was not effectively communicated or implemented, as evidenced by the lack of education on the grievance process during resident council meetings and the absence of documented resolutions for grievances. Interviews with staff, including the Social Service Designee and a Certified Nurse Aide, revealed a lack of knowledge about the grievance process and inconsistent follow-up on grievances. Furthermore, the facility's grievance reports for a specific resident's family member showed incomplete documentation, with no indication of resolution or notification to the complainant. The facility's failure to address grievances effectively was further highlighted by a family member's statement that grievances were not followed up on, leading to a lack of trust in the grievance process. The Administrator and Director of Nursing acknowledged that grievances should be discussed at resident council meetings, but this was not being done. The facility's grievance forms did not require signatures from residents or family members to confirm satisfaction with resolutions, indicating a gap in the grievance handling process.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop individualized, person-centered comprehensive care plans for two residents, leading to deficiencies in addressing dehydration, falls, and code status. Resident #15, who was severely cognitively impaired and dependent on a walker, had a history of falls and dehydration but did not have these issues addressed in their care plan. Despite having a fall on 4/14/24 and being hospitalized for acute kidney injury and dehydration on 4/15/24, the care plan lacked specific interventions for these conditions. Interviews with facility staff, including the MDS Coordinator, Director of Nursing, and Assistant Director of Nursing, revealed an expectation that such issues should have been care planned. Resident #44, also severely cognitively impaired, had a DNR order signed on 8/23/22, but this was not reflected in their care plan as of 6/4/24. The resident's annual MDS indicated severe cognitive impairment and various diagnoses, including dementia and anxiety, but the care plan failed to address the resident's code status. Interviews with the MDS Coordinator, Director of Nursing, and Assistant Director of Nursing confirmed that code status should have been included in the care plan. The facility's policy on comprehensive care planning emphasizes the need for individualized plans with measurable goals and time frames, which should be revised as changes occur in a resident's condition. However, the facility did not adhere to this policy for Residents #15 and #44, resulting in deficiencies related to the lack of care planning for falls, dehydration, and code status. The facility census at the time was 59.
Medication Administration Delays
Penalty
Summary
The facility failed to ensure that medications were administered within the appropriate time frame, affecting three residents. Resident #28 was prescribed Levothyroxine to be administered at 5:00 A.M. for hypothyroidism, but it was documented as being administered late at 7:33 A.M. The Director of Nursing (DON) was observed administering the medication at 7:32 A.M. after initially being delayed by staff cleaning the resident. Resident #21 had multiple medications prescribed, including Levothyroxine and Ropinole, which were also administered late. The medications were due at 5:00 A.M. but were given at 7:45 A.M. The DON acknowledged the delay, stating that the medications were early morning doses. Similarly, Resident #29 was prescribed Gabapentin to be administered at 6:00 A.M., but it was documented as being administered at 7:47 A.M. The DON confirmed that medications should be passed within one hour before or after they were due.
Deficiencies in ADL Assistance and Incontinence Care
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADL) for residents who required it, specifically in the areas of bathing and incontinence care. This deficiency affected four out of 17 sampled residents. Two residents did not receive regular showers, and two others did not receive complete incontinence care. The facility's policies on perineal care and resident rights were reviewed, but no policy on showers was provided. Resident #4, who had no cognitive impairment and required partial assistance with personal hygiene, was observed with greasy and uncombed hair, wearing the same clothes for consecutive days. The resident reported not receiving regular showers, with records showing infrequent showers over several months. Interviews with staff revealed a lack of dedicated shower aides and insufficient staffing to ensure regular showers for residents. Resident #43, with severely impaired cognitive skills and requiring substantial assistance with ADLs, also did not receive regular showers. Family members reported the resident received a shower approximately once a week, sometimes after two weeks. Incontinence care for Residents #33 and #40 was inadequately performed, with staff failing to follow proper procedures for cleaning and using the same area of wipes or washcloths for different skin areas. Interviews with staff confirmed these improper practices and acknowledged the need for correct cleaning techniques.
Deficiencies in Resident Care and Supervision
Penalty
Summary
The facility failed to ensure residents were free from accident hazards and provided with adequate supervision to prevent accidents. Specifically, Resident #27 was not served the correct therapeutic diet as ordered by the physician. Despite having a diagnosis of dementia and dysphagia, the resident was repeatedly served the wrong type of meat, which was not minced and moist as required. This issue was observed multiple times, and the Speech Language Pathologist (SLP) had to intervene to correct the diet. The dietary staff and kitchen personnel were aware of the resident's dietary needs but failed to consistently follow the prescribed diet orders. Resident #49, who was severely cognitively impaired, had a controlled medication, clonazepam, left on a card table in their room for two days. The medication was not administered as per the physician's orders, and there was no documentation of missed doses. The facility's policy required staff to remain with the resident while they took their medication, but this was not followed, leading to the medication being left unattended. This oversight was contrary to the facility's inservice training, which emphasized that medications should not be left in resident rooms. Additionally, the facility did not use proper techniques during the use of a sit-to-stand lift for Resident #43, who required substantial assistance with transfers. The lift pad slid up past the resident's armpits during a transfer, causing discomfort and potential risk of injury. The staff did not follow the manufacturer's guidelines for the lift, which included keeping the legs of the lift open for stability and ensuring the brakes were locked when raising or lowering the resident. The resident expressed pain during the transfer, indicating improper handling by the staff.
Staffing Shortages Lead to Multiple Deficiencies
Penalty
Summary
The facility failed to ensure sufficient staffing to meet the needs of its residents, resulting in several deficiencies. One resident, who required substantial assistance with activities of daily living due to severe cognitive impairment and mobility issues, did not receive regular showers. The resident's shower schedule was inconsistent, with significant gaps between showers, and family members reported that they often had to request showers after two weeks without one. Interviews with staff revealed that there was no dedicated shower aide, and the responsibility was assigned to aides on the halls, leading to missed showers when staff were unavailable. Additionally, the facility experienced delays in meal service, affecting all residents. Observations showed that meals were consistently served late, with lunch trays being delivered and served well after the scheduled times. Staff interviews indicated that the delays were often due to insufficient staffing, with only two staff members available to assist residents to the dining room. This shortage also impacted other aspects of care, such as timely administration of medications and the ability to lay residents down after meals. The facility also failed to provide timely medication administration for several residents. Medications that were scheduled for early morning administration were given late, as observed during the survey. The Director of Nursing was seen administering medications hours after they were due, citing staffing issues as a reason for the delay. Furthermore, the Activity Director was frequently pulled from their role to cover staffing shortages on the floor, resulting in canceled activities for residents. The facility did not provide policies for staffing or showers, contributing to the deficiencies observed.
Medication Administration Errors and Policy Non-Compliance
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, resulting in a rate of 32.14% due to nine errors out of 28 opportunities. This affected five residents, including those who received insulin injections not administered according to manufacturer guidelines. Specifically, the Assistant Director of Nursing (ADON) did not hold the insulin needle in the skin for the required six seconds, as observed with two residents. The ADON admitted to counting only three or four seconds, contrary to the manufacturer's instructions. Additionally, the facility did not adhere to proper procedures for transdermal patch application and removal. A Licensed Practical Nurse (LPN) failed to remove a Lidocaine patch from a resident's hip at the designated time, leaving it on overnight. The patch was supposed to be removed after 12 hours, but it was not dated, timed, or initialed, indicating a lapse in following physician orders and facility policy. The facility also did not follow proper procedures for medication administration, including crushing medications that should not be crushed. A Certified Medication Technician (CMT) crushed several medications, including Metformin ER and multivitamins, which should have been administered whole. Furthermore, the CMT did not apply lacrimal pressure after administering eye drops to a resident, as required by the facility's policy and manufacturer guidelines.
Medication Storage and Management Deficiencies
Penalty
Summary
The facility failed to ensure medications were stored securely, as observed on multiple occasions where medication carts were left unlocked and unattended. Registered Nurse (RN) and Licensed Practical Nurse (LPN) were seen leaving medication carts unlocked in various areas, such as the dinette and hallway, without any staff in visual contact. This occurred despite the facility's policy requiring medication carts to be locked when unattended. Interviews with the nursing staff confirmed that they were aware of the requirement to lock the carts but failed to do so consistently. Additionally, the facility did not properly manage medications for a resident with severe cognitive impairment. The resident, who was on antipsychotic, antianxiety, and antidepressant medications, was found to have a clonazepam tablet left unsecured in their room. The medication administration record showed a missed entry for clonazepam, and the resident had no assessments to self-administer medications. This oversight was acknowledged by the LPN, who confirmed the pill belonged to the resident and should not have been left in the room. The facility also failed to discard an expired vial of Influenza Vaccine and did not ensure a bottle of Lactulose Solution had a pharmacy label. The Director of Nursing (DON) confirmed that the expired vaccine should have been discarded and that the Lactulose should have been labeled with the resident's name. These lapses in medication management were identified during an observation and interview in the medication room, highlighting a lack of adherence to proper medication storage and labeling protocols.
Inadequate Dietary Staffing and Unsanitary Kitchen Conditions
Penalty
Summary
The facility failed to provide adequate staffing in the dietary department, leading to delays in meal service and unsanitary kitchen conditions. Observations revealed that meals were consistently served late, with lunch trays being delivered and served well past the posted meal times. Residents reported that meals were often delayed by at least 30 minutes. The facility's open dining policy was not adhered to, as evidenced by the late delivery and serving of meals in both the memory care unit and the dining room. The kitchen was found to be in an unsanitary state, with unclean tables, food residue on various surfaces, and a lack of proper cleaning and maintenance. The cleaning logs were incomplete, with no entries for several days and weeks, indicating a failure to follow the facility's cleaning schedules. The dietary manager and staff reported high turnover and insufficient staffing, which contributed to the inability to maintain cleanliness and timely meal service. The dietary manager also lacked prior food service experience and adequate training, further exacerbating the issues. Interviews with staff highlighted the challenges faced due to the workload and lack of training. The dietary aide position was difficult to fill, and new employees often left shortly after starting due to the demands of the job. The dietary manager expressed the need for additional help and training to effectively manage the department. The facility did not provide a policy regarding dietary staffing, which may have contributed to the ongoing issues in the dietary department.
Failure to Serve Food at Safe and Appetizing Temperatures
Penalty
Summary
The facility failed to ensure that food served to residents was palatable, attractive, and at a safe and appetizing temperature. Observations and interviews revealed that hot food was not served at an appetizing temperature to three residents out of a sample of fifteen. The facility's policy required hot foods to be at least 120 degrees Fahrenheit when served, but several food items were found to be below this temperature during a meal test tray observation. For instance, fish was served at 99.2 degrees, carrots at 111.9 degrees, and baked beans at 104.6 degrees, all below the required serving temperature. Resident interviews highlighted dissatisfaction with the food temperatures and quality. One resident reported that hot food was typically cold, and cold food was too warm, while another resident mentioned that their food was cold. Additionally, the appearance and texture of the meals were noted to be unappetizing, with overcooked vegetables and soggy chicken nuggets. The dietary manager and dietician both expressed expectations that staff should ensure food is served at the correct temperature, with procedures in place to reheat food if necessary. However, these expectations were not met, leading to the deficiency.
Inaccessible Call Lights for Residents
Penalty
Summary
The facility failed to ensure that the call light system was accessible for residents in their rooms, as observed in the cases of two residents. Resident #43, who had severe cognitive impairment, impaired mobility, and a history of falls, was found with the call light draped over the foot of the bed, out of reach. Despite the resident's care plan indicating the need for the call light to be within reach at all times, staff left the room without ensuring the call light was accessible, requiring family intervention to rectify the situation. Resident #44, who was severely cognitively impaired and had multiple health issues including dementia and impaired vision, was observed multiple times with the call light on the floor or hanging out of reach. This resident, who was at risk for falls, had to leave the bed to seek assistance, indicating a failure to provide the necessary accessibility to the call light. Staff did not ensure the call light was within reach even after assisting the resident back to bed. Interviews with various staff members, including a Registered Nurse, Licensed Practical Nurse, Certified Nurse Aide, MDS Coordinator, Director of Nursing, Assistant Director of Nursing, and the Administrator, all confirmed the expectation that call lights should be within residents' reach. Despite this, the observations showed a consistent failure to adhere to this standard, as evidenced by the repeated instances of inaccessible call lights for the two residents.
Breach of Resident Privacy Due to Unattended Computer Screen
Penalty
Summary
The facility failed to protect residents' personal privacy when a Licensed Practical Nurse (LPN) left the medication cart computer screen unattended, unlocked, and visible with resident personal information accessible to anyone nearby. This occurred multiple times on the morning of June 11, 2024, with the computer screen being left open and visible to resident confidential information for several minutes at a time. The LPN left the medication cart unattended while entering various rooms and the dining area, leaving the computer screen exposed in a public area. Interviews with the LPN and the facility's Director of Nursing (DON) and Assistant DON revealed that the staff was expected to lock the computer screen or shut it down when leaving the medication cart unattended to protect residents' privacy. The facility's policy on electronic medical records and resident rights emphasized the importance of maintaining confidentiality and preventing unauthorized access to resident information. Despite these policies, the LPN did not adhere to the expected procedures, resulting in a breach of resident privacy.
Failure to Identify and Document Pressure Ulcer
Penalty
Summary
The facility failed to identify, assess, and document a pressure ulcer for Resident #43, who was admitted with a left hip fracture and dementia. Upon admission, the resident's skin integrity was noted to have a surgical wound, but no other skin issues were documented. However, on 1/26/24, it was noted that the resident had developed a Stage II pressure ulcer on the left heel, which was not identified until the resident's family member discovered it. The ulcer measured 5 cm x 4 cm with a black center and serous drainage, indicating a lack of timely skin assessment and documentation by the facility staff. The resident's medical records and progress notes revealed that the resident had been primarily bedridden since admission and required assistance for transfers. Despite this, the facility did not implement adequate preventive measures such as heel protectors or regular repositioning to prevent pressure ulcers. The resident's condition was further complicated by cognitive impairment, requiring substantial assistance with daily activities, and the presence of a suprapubic catheter, which increased the risk of skin breakdown. Interviews with the Director of Nursing (DON) and Registered Nurse (RN) A confirmed that the resident was not admitted with a pressure ulcer on the left heel, and the weekly skin assessments were not completed as required. The DON acknowledged that the nurses should have identified the wound before the family did, indicating a lapse in the facility's wound care and prevention protocols. This deficiency highlights the facility's failure to adhere to its own policies for ongoing skin assessment and pressure ulcer prevention, leading to the development and progression of the resident's pressure ulcer.
Failure to Follow Dietary Guidelines and Portion Sizes
Penalty
Summary
The facility failed to ensure that meals were served according to the nutritional needs and dietary requirements of the residents. Observations revealed that staff did not follow the prescribed recipes and portion sizes as outlined in the facility's menu. Specifically, during meal preparation, staff did not use the correct ingredients or follow the recipes for minced and moist diets, and they failed to use the appropriate serving utensils, resulting in inconsistent portion sizes. This inconsistency in meal preparation and serving had the potential to affect all residents in the facility. Interviews with staff members, including the dietary manager and the dietician, confirmed that there was a lack of adherence to the menu and recipe guidelines. Staff members admitted to not using the menu book for preparing meals and instead relied on their own judgment or previous instructions from former managers. This led to incorrect portion sizes being served, with some residents receiving more or fewer pieces of chicken than specified in the menu. Additionally, the dietary manager acknowledged that prior to their tenure, staff were unaware of the location of the recipe book, indicating a lack of proper training and oversight. The dietary manager and dietician both expressed expectations that staff should follow the recipes and use the correct serving utensils as indicated in the menu. However, the staff's failure to do so resulted in meals that did not meet the nutritional needs of the residents. The administrator also expected adherence to the menu and recipe guidelines, but the observations and interviews highlighted a significant gap between these expectations and the actual practices in the kitchen.
Failure to Adhere to Dietary Orders for Resident
Penalty
Summary
The facility failed to prepare food in a form designed to meet individual needs, specifically for Resident #27, who was served food inconsistent with their dietary orders. Resident #27, who had a diagnosis of dementia and mild protein-calorie malnutrition, was on a therapeutic diet requiring minced and moist level 5 meats. However, observations revealed that the resident was served regular bacon and scrambled eggs instead of the prescribed minced and moist diet. This discrepancy was noted by the speech language pathologist (SLP), who intervened to correct the meal. Further observations showed that the resident was again served the wrong diet at lunch, receiving pureed meats instead of the ordered minced and moist meats. Interviews with staff, including the SLP, dietary manager, and certified nurses aides (CNAs), indicated that serving incorrect diets was an ongoing issue within the facility. The dietary manager acknowledged awareness of the problem and emphasized the importance of following physician-ordered diets to prevent choking incidents. Interviews with various staff members, including the Director of Nursing (DON) and Assistant DON, revealed a general expectation that dietary orders should be followed accurately. Despite in-service education provided to staff on ensuring correct diet orders, the issue persisted, with staff admitting to occasionally serving incorrect diets. The facility's failure to consistently adhere to dietary orders resulted in Resident #27 being served inappropriate meals, highlighting a significant deficiency in dietary management.
Inadequate Hand Hygiene Practices Observed
Penalty
Summary
The facility failed to maintain proper infection prevention and control practices, as evidenced by staff not washing their hands between dirty and clean tasks. This deficiency was observed during interactions with a resident who had severe cognitive impairment, required substantial assistance with daily activities, and had a suprapubic catheter and a Stage II pressure ulcer. The resident was on enhanced barrier precautions due to these conditions, which necessitated strict adherence to infection control protocols. During observations, it was noted that a CNA and an LPN did not wash their hands between glove changes while providing care to the resident. The LPN removed gloves after cleaning the resident's coccyx and applied new gloves without washing hands. Similarly, a CMT and another NA also failed to wash their hands between glove changes while assisting the resident with transfers and personal care. These actions were contrary to the facility's handwashing policy, which, although undated, aimed to reduce the transmission of organisms. Interviews with staff, including the DON, revealed a lack of consistent understanding and adherence to hand hygiene protocols. Staff members acknowledged the importance of washing hands when entering a resident's room, between glove changes, and after providing care, especially when dealing with fecal material. However, the observed practices did not align with these expectations, indicating a gap in the implementation of infection control measures.
What surveyors are citing around you — mapped
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Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 20 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Maryville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Village Care Center Inc | 0.6 mi | ★★★★★ | 1 | 0 |
| Parkdale Manor Health & Rehabilitation | 1.6 mi | ★★★★★ | 1 | 0 |
| Nodaway Healthcare | 5.3 mi | ★★★★★ | 2 | 0 |
| Pine View Manor Inc | 19.7 mi | ★★★★★ | 1 | 0 |
| Bedford Specialty Care | 23.3 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.