Below average — CMS composite of the measures below.
A standard survey is most likely before around November 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 Nodaway Healthcare during CMS and state inspections, most recent first.
A resident with moderate cognitive impairment, multiple comorbidities, prior fractures, and recent falls required two-person assistance for transfers per the care plan. A CNA nonetheless performed a one-person, face-to-face transfer from wheelchair to bed without a gait belt, despite other staff being present, and proceeded to put the resident to bed after the resident stated they did not want to go. Witnesses, including a NA and a CMT, reported the CNA was verbally harsh, aggressive, and rough during the transfer, did not offer the resident a choice about going to bed, and that the situation was not an emergency. The resident reported shoulder and leg pain associated with how the CNA grabbed and pushed their legs onto the bed.
RN Coverage and DON Staffing Deficiency: The facility failed to provide an RN for 8 consecutive hours per day, 7 days a week, and failed to have an RN serving as DON on a full-time basis. PBJ data and staffing schedules showed multiple days with no RN coverage, and staff interviews confirmed there was no documentation showing RN coverage on those dates. The Regional Nurse questioned the accuracy of the PBJ, the ADON reported staffing problems and no supporting documentation, and the Administrator stated the facility should have an RN working 8 hours a day, 7 days a week.
Failure to complete TB screening and maintain water management program: The facility did not have two-step TB skin test documentation for three employees reviewed, despite its policy requiring TB screening for all new hires before beginning work. The DON/ Infection Preventionist could not explain the missing results. The facility also had no water management plan or program for Legionella prevention, and the Maintenance Supervisor and DON both stated that no such program was in place and Legionella testing had not been done.
Failure to Inform Residents of Psychotropic Medication Risks and Benefits: The facility did not document that two residents, or their representatives, were fully informed in advance of the risks and benefits of antipsychotic, psychotropic, or antidepressant medications. One resident with dementia, TBI, and behavioral disturbance received Haldol, and another resident with dementia, psychotic disorder, and depression received aripiprazole and citalopram; both records lacked consent or education documentation.
Failure to Offer Bedtime Snacks: Residents reported that bedtime snacks were not being offered, despite facility policy stating snacks are available 24 hours a day. In a group interview, all residents expressed concern about the lack of bedtime snacks, and most said they would accept one if offered. Staff gave inconsistent accounts of snack cart timing and distribution, with some saying snacks were only available if residents asked, while others said snacks were passed on evening or night shift.
Failure to Post Grievance and State Hotline Information: Six of six residents said they did not know where to find the State Agency complaint information, the hotline number, or how to file a grievance. Observations showed no posted sign with State Agency contact information, and staff including CNAs, an LPN, the DON, and the Administrator were unsure whether the abuse hotline number was posted or where it was located.
Privacy and Consent Failures With Room Camera Surveillance: The facility failed to maintain confidentiality for three residents when room camera surveillance was used without required signage at the entrance and outside resident rooms, and without signed consents for two residents. One resident was alert and ambulatory with a walker, one had a BIMs of 10 and was on hospice with multiple comorbidities and falls, and one had dementia, memory loss, and extensive ADL dependence. Records showed no policy for video surveillance with or without audio, no care plan address for the cameras, and observations confirmed monitors in resident rooms and audio available at the nurses' station.
Failure to Complete Required Pre-Employment Screening: Surveyors found the facility did not verify CNA registry status for 9 of 10 sampled staff, including an LPN, CMT, SSD, NAs, CPs, nurses, and an administrator, and two staff did not have a criminal background check on file before their first day of work. The facility’s abuse and neglect policy required pre-employment screening to include criminal history, background checks, and registry checks, but records were incomplete and the BOM could not provide all required documentation.
Failure to Provide Transfer/Discharge Notices and Ombudsman Information The facility did not provide required bed hold information, discharge summaries, appeal rights, or Ombudsman contact details for several residents transferred or discharged from the facility. Records for multiple residents lacked documentation of the reason for discharge, where they were sent, whether they returned, and whether personal belongings were retrieved. The chart also did not show that the Ombudsman was notified of the discharges, and one resident’s discharge summary was left incomplete.
Incomplete care planning for oxygen therapy, hospice needs, and recurrent falls. The facility did not include oxygen therapy in the care plans for two residents with COPD, hypoxia, or oxygen use, and did not document hospice/end-of-life care or colon cancer care for a resident on hospice with severe cognitive impairment and cancer. The facility also failed to update a resident’s fall care plan after repeated falls, despite the resident’s significant change in status and multiple documented falls.
Improper Perineal and Catheter Care During ADL Assistance: Staff were observed providing peri care and catheter care using the same wipe area multiple times, failing to change gloves or perform hand hygiene, and not fully cleaning skin folds, buttocks, or catheter tubing. A resident with a catheter and limited mobility, another resident with COPD and a catheter, and two residents with severe cognitive and mobility impairments were all observed receiving incomplete hygiene care, and staff also failed to provide oral care, face and hand washing, and hair care before meals.
Respiratory care was not properly provided when staff failed to keep oxygen tubing dated, failed to clean or replace oxygen concentrator filters, failed to have a filter installed on one resident’s concentrator, and failed to obtain a physician order for oxygen for a resident who was receiving oxygen therapy. One resident with COPD had tubing and a humidifier bottle dated months earlier and filters covered in lint, while another resident with severe cognitive impairment was using an oxygen concentrator without an order in the chart. A third resident with COPD had no filter on the concentrator during observations, despite orders for weekly oxygen equipment changes.
Expired and improperly labeled meds were found in the med room and a CMT/nurse med cart. Surveyors observed an opened TB vial past the 30-day limit, expired flu vaccines, eye drops and oral meds without opening dates, a torn-off label with ondansetron tablets, Resident #23’s expired lidocaine viscous, and an albuterol inhaler with conflicting resident identification. Staff stated they were unsure about expiration dates and labeling, and acknowledged that expired meds should not be used.
Food storage, sanitation, and hand hygiene were not maintained as required. Surveyors found expired leftovers in the refrigerator, rotten and moldlike food items, unlabeled and undated products, food stored on the floor, rusted and dirty shelving, grime under the dishwasher, and a dirty ice machine. Staff were also observed serving resident trays and handling food without sanitizing or washing hands between tasks, including after glove changes and upon entering the kitchen.
The facility failed to submit complete and accurate PBJ staffing data for the quarter. Review showed no RN coverage hours on multiple days and no licensed nurse on several dates, and staffing schedules also showed no RN on several days. Staff interviews confirmed the PBJ did not appear to be filled out correctly, documentation for RN coverage could not be found for the listed dates, and the Administrator stated the PBJ should be completed correctly and that an RN should work 8 hours a day, 7 days a week.
Failure to follow a resident's hearing aid care plan. A resident with severe cognitive impairment and documented hearing difficulty was care planned to have bilateral hearing aids available, functioning, fully charged, and in place, but the resident was very hard of hearing and staff had to speak loudly and directly to be understood. The resident said two hearing aids should exist but did not know where they were, and CNA and RN interviews confirmed no hearing aids were found in the room. The DON said the resident did not like the hearing aids and staff had trouble getting the resident to wear them, while the ADON said she was not familiar with whether the resident had hearing aids.
Failure to update fall interventions and fall risk assessment for a resident with repeated falls. A resident with dementia, confusion, incontinence, and dependence for ADLs had multiple unwitnessed and witnessed falls, including one event with head pain, swelling, bruising, lethargy, and hospital transfer. Although the care plan identified high fall risk and listed interventions, staff did not add new interventions after each fall, and the DON stated fall interventions should be developed and the fall risk updated after each new fall.
A resident admitted after a vehicle accident did not receive pain medication for 48 hours due to pending orders and communication breakdowns. Despite staff efforts to contact the primary care provider and pharmacy, the resident experienced significant pain and anxiety. The facility's emergency medication kit lacked the necessary narcotic, and the Director of Nursing and Administrator were not adequately informed.
A resident with respiratory issues did not have their nebulizer equipment cleaned and stored properly, as required by facility policy. The nebulizer tubing and mouthpiece were left attached and placed on the bed, contrary to the procedure of cleaning, air-drying, and storing in a marked plastic bag. Staff interviews confirmed the oversight, leading to potential contamination.
The facility failed to return personal funds within 30 days for two residents after discharge, as required by policy. The Business Office Manager submitted refund invoices to the corporate office, but checks were not processed and signed in a timely manner, resulting in a deficiency.
Failure to Honor Resident Choice and Provide Safe, Dignified Transfer
Penalty
Summary
The deficiency involves a failure to honor a resident’s right to dignity, respect, self-determination, and safe care during a transfer from wheelchair to bed. A CNA transferred the resident without securing the assistance of another staff member and without using a gait belt, contrary to the resident’s care plan and facility policy. Witnesses, including a NA and a CMT, reported that the CNA performed a one-person transfer from the wheelchair to the bed and did so aggressively and roughly, without giving the resident a choice about going to bed. The resident involved was moderately cognitively impaired and had multiple diagnoses, including coronary artery disease, hypertension, kidney disease, hip fracture, dementia, psychotic disorder, asthma, and acute pain due to trauma. The MDS indicated the resident required staff supervision or touching assistance for sitting-to-lying and lying-to-sitting mobility, and partial or moderate staff assistance for sit-to-stand and transfers between chair and bed. The care plan documented that the resident required two-person assistance for transfers between chair and bed, had a healed right femur fracture and vertebral fractures, and had a history of difficulty asking for assistance due to a strong sense of independence. The resident had also experienced two falls with pain in the left hip and shoulder shortly before the incident. On the evening of the incident, the resident stated that they told the CNA they did not want to go to bed, but the CNA proceeded anyway. The CNA acknowledged that the resident protested going to bed and that a gait belt should have been used, but stated they felt it was imperative to transfer the resident immediately because the resident was sitting on the edge of the wheelchair. The CNA described performing a face-to-face transfer by placing their arms under the resident’s rib area and moving the resident in one motion to the bed. The resident reported that the transfer hurt, stating that their shoulder and legs hurt after the CNA grabbed and pushed their legs onto the bed. Witness staff reported that the CNA was verbally harsh, did not provide the resident with a choice about going to bed, and that the situation did not constitute an emergency requiring immediate intervention to prevent a fall.
RN Coverage and DON Staffing Deficiency
Penalty
Summary
The facility failed to provide an RN for eight consecutive hours per day, seven days a week, and also failed to select an RN to serve as DON on a full-time basis. Review of PBJ data for Quarter 2 2025 showed no RN coverage hours on 2/23, 3/2, 3/16, 3/29, and 3/30, and review of staffing schedules confirmed no RN on 2/23, 3/2, 3/16, 3/29, and 3/30. The facility census was 30, and no policy for RN coverage was provided. During interviews, the Regional Nurse stated she knew something was not right with the PBJ and did not think it had been filled out correctly. The ADON stated the facility had a rough time with staffing early in the year, could not find documentation showing RN coverage on those dates, and reported that the MDS/Care Plan Coordinator had taken over as DON about three months earlier. The Administrator stated the PBJ should be filled out correctly and that the facility should have an RN working eight hours a day, seven days a week.
Failure to Complete TB Screening and Maintain Water Management Program
Penalty
Summary
The facility failed to complete TB skin testing for three of ten employees reviewed. Review of the Employee TB Screening and interpretation of Results Policy, revised July 2010, showed that all employees are to be screened for TB infection and disease using a two-step tuberculin skin test prior to beginning employment, with the second dose given 7-21 days after the first dose. Review of employee records on 08/06/25 showed that CMT A, hired 11/04/24, CNA A, hired 11/11/24, and CNA B, hired 03/14/25, had no two-step TB testing in their employee files. During interview, the DON/ Infection Preventionist stated that new hires are to have a two-step TB skin test upon hire and that documentation is kept in a binder in her office, but she could not explain where the missing TB testing results were. The facility also failed to establish and maintain an effective water management program to address Legionella and other waterborne pathogens. The facility did not provide a water management plan or policy regarding prevention of waterborne pathogens. During interview, the Maintenance Supervisor stated there was currently no established program to address prevention of Legionella in the water system at the facility and that testing for Legionella had not been done. During a later interview, the DON stated there was currently no water management plan or program in place for Legionella prevention at the facility.
Failure to Inform Residents of Risks and Benefits of Psychotropic Medications
Penalty
Summary
The facility failed to ensure that two sampled residents and/or their representatives were fully informed of the risks and benefits of physician-ordered antipsychotic medications. The report states that the facility did not have documentation showing that the residents were informed in advance about the risks and benefits of taking antipsychotic, psychotropic, or antidepressant medications. One resident had diagnoses including dementia, traumatic brain injury, anxiety, cancer, malnutrition, and non-traumatic brain dysfunction, and was receiving Haldol 5 mg by mouth in the evening for behavioral disturbance and mood disorder. The resident's MDS showed no behaviors, dependence on staff for multiple activities of daily living, frequent bowel and bladder incontinence, and multiple falls. The care plan identified psychotropic medication use and stated that the resident, family, and caregivers should be educated about risks, benefits, and side effects, but the medical record reviewed from 7/1/25 through 8/6/25 contained no consents or education regarding psychotropic medication risks and benefits. The other resident had moderate cognitive impairment and diagnoses including dementia, paraplegia, multiple sclerosis, depression, psychotic disorder, and neurogenic bladder. The resident received aripiprazole for delusions and major depressive disorder related to delusional disorders, along with citalopram and hydrocodone-acetaminophen. The care plan noted use of psychotropic medications and monitoring for adverse reactions, but the record contained no documentation that the facility fully informed the resident in advance of the risks and benefits of anti-psychotic, psychotropic, or anti-depressant medications.
Failure to Offer Bedtime Snacks
Penalty
Summary
The facility failed to promote an environment respectful of resident rights and self-determination when bedtime snacks were not offered to residents, despite facility policies stating that snacks are available 24 hours a day and may be requested as desired or scheduled between meals. During a group interview, six of six residents said they were concerned that staff did not offer bedtime snacks, and five of the six said they would take a snack at bedtime if it were offered. One resident also stated that no snacks are passed out before bedtime and that he or she would take a snack if offered. Staff interviews showed inconsistent practices regarding snack availability and distribution. A CNA stated that drinks and snacks are set on a cart by the nurse's station at 10:00 A.M. and that there is supposed to be a snack cart after supper, while another CNA said no one goes room to room to pass snacks and that residents only receive snacks if they say they are hungry. An LPN said snack cart timing depends on kitchen staff and that snacks are available on evening and night shift, not day shift. The Dietary Manager said CNAs are supposed to pass out snacks, but was not sure if snacks were passed every day and stated that before the day prior, the snack cart was only sent to the nurse's station at 6:30 P.M. The DON said residents can ask for snacks during the day and that CNAs ask residents before bedtime if they want a snack.
Failure to Post Grievance and State Hotline Information
Penalty
Summary
The facility failed to prominently display information on how residents could file a grievance or contact the Missouri Adult Abuse & Neglect hotline. During a group interview, six of six participants said the facility did not protect resident rights because the grievance and hotline information was not clearly posted for residents. The facility census was 30. Review of the facility's Resident and Family Concerns and Grievances Policy and Procedure showed residents are to be notified, individually or through prominent posting, of the right to file a grievance, including contact information for the relevant state agency or Ombudsman program. During a group interview, six of six residents said they did not know where the State Agency complaint information was displayed, did not know the phone number for filing a complaint, and did not know how to file a grievance. Observation on 08/05/2025 at 11:00 A.M. and again on 08/07/2025 at 11:00 A.M. showed no sign posted in the facility with information to contact the State Agency to file a complaint. Staff interviews reflected uncertainty about the posting: a CNA said the hotline number was on the wall but could not locate it, another CNA was not sure where it was located, an LPN said residents would be taken to the office for the business manager to give the number, and the DON and Administrator were not sure whether the State abuse hotline number was currently posted.
Privacy and Consent Failures With Room Camera Surveillance
Penalty
Summary
Keep residents' personal and medical records private and confidential was not maintained when the facility failed to post signage at the front entrance and outside the rooms of three sampled residents to indicate 24-hour camera surveillance was in use, and failed to obtain required consents for two of the residents. The facility also did not provide a policy for video surveillance with or without audio. The deficiency involved Resident #15, Resident #2, and Resident #30 in a facility with a census of 30. Resident #15 was alert and oriented to self and place, used a walker, wanted to remain independent, and had diagnoses including sequelae following cerebrovascular disease, left foot drop, muscle weakness, GERD, conversion disorder with seizures, restless leg syndrome, gait and mobility abnormalities, pain in the left ankle and foot, and a history of falls, with the last fall occurring in the hall. The resident's POS did not include an order for video surveillance with audio. Observation showed the resident in the room with video/audio surveillance on the roommate's side of the room, with no sign outside the room and no sign at the facility entrance. The monitor was at the nurses' station, and the audio was turned down at one point and later turned on so staff could hear TV and voices in the room. The care plan and progress notes did not address video/audio surveillance or consent, and the record did not contain a signed consent from the resident. Resident #2 had a BIMs of 10, was alert to person, place, and time, used a wheelchair, ambulated with a walker in the room, and had diagnoses including heart disease, non-Hodgkin's lymphoma, chronic kidney disease stage 4, hypertension, major depressive disorder, history of TIA, and cellulitis to both lower limbs. The resident was on hospice for heart failure and was identified as high risk for falls with poor safety awareness and several falls since admission. The care plan did not address video surveillance, there was no sign outside the room or at the entrance, and the record showed only verbal consent from the POA for video surveillance. The medical record did not contain a signed consent from the POA for 24-hour camera surveillance. Resident #30 had significant memory problems, required extensive assistance with ADLs and transfers, was frequently incontinent, had multiple falls, and had diagnoses including non-traumatic brain dysfunction, cancer, anxiety, arthritis, and dementia. The care plan did not address video surveillance, and the medical record did not contain a signed consent from the responsible party for 24-hour camera surveillance. Observation showed a video monitor on the bedside table aimed at the resident, with no sign outside the room indicating camera surveillance. A family member stated staff had placed the monitor in the room about a week earlier, had not discussed audio capability, had not asked for a consent, and had not informed the family before setting it up.
Failure to Complete Required Pre-Employment Screening
Penalty
Summary
Develop and implement policies and procedures to prevent abuse, neglect, and theft was cited after surveyors found the facility did not check the CNA Registry for 9 of 10 sampled staff to verify they did not have a Federal Indicator for abuse or neglect. The staff members without a CNA registry check on file included LPN B, CMT A, SSD, Nursing A, Nursing B, Nursing C, [NAME] A, NA A, CP A, and Administrator 2. The facility census was 30. Review of the facility’s Abuse and Neglect Procedure showed pre-employment screening was to include criminal history check, background check, reference check from previous employers, professional licensure, certification, or registry check as applicable, Registry and OIG, and that the facility would not hire or retain any employee with a history of abuse or neglect if known to the home. Record review showed SSD, LPN B, NA A, CP A, [NAME] A, Nurse B, Nurse C, and Administrator 2 had no CNA registry check on file. CMT A and Nurse A also did not have a criminal background check prior to their first working day or on file. During interview, the BOM stated she could provide 8 of 10 CBCs, 10 of 10 EDLs, and 1 of 10 Certified Nurse Registry checks, and that the two missing CBCs had been completed but not uploaded to the system. The Administrator stated CBCs and EDLs were to be completed prior to staff being able to start work.
Failure to Provide Required Transfer and Discharge Notices
Penalty
Summary
The facility failed to provide required transfer and discharge documentation to residents and their representatives, including the bed hold policy, discharge summaries, reasons for discharge, appeal rights, and the Office of the State Long-Term Care Ombudsman contact information. The report states that this affected five of 12 sampled residents and that the facility also failed to notify the Ombudsman of discharges. Facility policy required a 30-day written notice for transfer or discharge, documentation of the reason for the transfer or discharge in the medical record, and written notice to the resident and/or representative that included appeal rights, bed hold policy, and Ombudsman contact information. For Resident #1, the record showed the resident was sent to the hospital for shortness of breath after admission for bowel resection and multiple diagnoses including Crohn’s disease, kidney disease, respiratory failure, anemia, and sepsis. The chart did not include documentation explaining why the resident did not return to the facility, whether personal belongings were picked up, or where the resident was discharged to. The record also did not show that a bed hold notice was provided or that the Ombudsman was notified of the discharge. For Resident #6, who was admitted with adult failure to thrive, anorexia, heart disease, hypertension, and type 2 diabetes, the physician gave the resident a choice between hospice and hospital transfer due to failure to thrive and weight loss, and the resident chose hospital transfer. The notes did not show that the DPOA was notified of the transfer or informed that the resident could return after discharge from the hospital. The chart also lacked documentation that the Ombudsman was notified, did not explain how staff were informed that the resident was not returning, and did not show whether family retrieved personal belongings or what happened to the resident after discharge. For Resident #4, who was severely cognitively impaired and had diagnoses including deep venous thrombosis, kidney disease, obstructive uropathy, hip fracture, epilepsy, and Down syndrome, the resident was hospitalized for leg pain after an x-ray order was given. The medical record did not show that the bed hold policy or discharge summary was provided to the resident or representative, and the admission/discharge report did not show the resident’s discharge to the hospital or the date of readmission. For Resident #12, who had severe cognitive impairment, stroke, hemiplegia, and significant functional dependence, the resident was sent out after vomiting and sweating, with EMS called after the PCP directed transfer for further evaluation. The record did not show when the resident returned to the facility or that the transfer/discharge paperwork and bed hold had been discussed with or signed by the responsible party. For Resident #8, the discharge summary was not completed, and there was no charting showing that the Ombudsman had been notified of the discharge. The electronic medical record also did not contain a discharge summary with continuance of care at the time of discharge. The DON stated the resident had been admitted for therapy and that the prior discharge summary had been completed on an earlier discharge, but it was not complete during the most recent discharge.
Incomplete Care Planning for Oxygen Therapy, Hospice Needs, and Recurrent Falls
Penalty
Summary
The facility failed to ensure staff developed and implemented a person-centered comprehensive care plan for three sampled residents. For Resident #31, the record showed diagnoses of COPD, mild cognitive impairment, and acute respiratory failure with hypoxia, along with physician orders for oxygen titration up to 6 liters per minute via nasal cannula to keep SpO2 above 91%, weekly humidifier changes, and weekly oxygen tubing and storage bag changes. The current care plan did not include the use of oxygen as needed to maintain SpO2 above 91%. For Resident #3, the significant change MDS showed memory problems, dependence on staff for multiple activities of daily living, substantial to maximum assistance with transfers, frequent bowel and bladder incontinence, and multiple falls. The care plan, revised 7/24/25, identified the resident as high risk for falls and included general interventions such as keeping the call light within reach and ensuring prompt response to requests for assistance, but it was not updated with each new fall. The medical record showed falls on 5/24/25, 5/25/25, 5/27/25, 5/31/25, 6/1/25, 6/2/25, 6/4/25, 6/5/25, 7/2/25, 7/8/25, and 7/11/25. For Resident #30, the quarterly MDS showed severe cognitive impairment, oxygen therapy, hospice care, and diagnoses including cancer, kidney disease, CAD, pneumonia, and malnutrition, but the care plan did not document hospice end-of-life care, colon cancer care planning, or oxygen use for shortness of breath. The resident’s hospice orders included morphine concentrate PRN for shortness of breath or pain and Levsin PRN for secretions, and the resident was observed using an oxygen concentrator while stating a preference to use oxygen most of the time to prevent dizziness.
Improper Perineal and Catheter Care During ADL Assistance
Penalty
Summary
The facility failed to ensure proper perineal and catheter care for residents who were dependent on staff for assistance with activities of daily living. The report states that the facility policy required female perineal care to be performed front to back, with separate labia cleaned downward, and that catheter care required gentle cleansing from the urethra down the catheter tubing. During observation, CNA staff were seen using the same wipe area multiple times, failing to change gloves after care, and not performing hand hygiene before placing clean briefs on residents. Resident #28 had limited physical mobility related to neurological deficits, was incontinent of bowel, and had an indwelling urinary catheter. During lunch preparation, the resident was observed soiled with urine, and CNA B wiped front to back multiple times using the same area of the wipe, did not change gloves after perineal care, and did not perform hand hygiene. CNA B later stated the wipe should have been clean with each swipe. Resident #16 had COPD, activity intolerance, episodes of shortness of breath, bowel incontinence, and a urinary catheter. CNA A was observed assisting the resident to the toilet and wiping the catheter from the insertion site down the tubing with the same wipe multiple times, then wiping the perineal area front to back with the same wipe twice, and placing a new brief without changing gloves or performing hand hygiene. Resident #3 had severe cognitive impairment, was dependent on staff for eating, toileting, dressing, showers, and personal hygiene, and was frequently incontinent of bowel and bladder. During morning care, CNA B and CNA A were observed cleaning the resident with repeated use of the same wipe area across groin folds and buttocks, including wiping fecal material and folding the wipe to reuse it. The staff did not separate and clean all skin folds, did not clean the buttocks fully, and did not provide oral care, wash the face and hands, or comb the resident's hair before taking the resident to the dining room. Resident #12 had severe cognitive impairment, hemiplegia, and was dependent for personal hygiene and transfers; staff were observed using the same wipe area repeatedly on fecal material, not cleaning the front perineal folds or buttocks adequately, and not providing oral care, face and hand washing, or hair care before breakfast.
Respiratory Care Deficiencies With Oxygen Equipment and Orders
Penalty
Summary
Safe and appropriate respiratory care was not provided when staff failed to properly manage oxygen equipment for multiple residents. The facility’s Oxygen Administration policy required a physician’s order before oxygen was administered and required documentation of the date and time of setup or adjustment, the staff member performing the procedure, the oxygen flow rate, and the frequency of treatment. The report identified failures involving dated oxygen tubing, oxygen concentrator filters, and the presence of required equipment components. For one resident with intact cognition, impaired lower extremity function, depression, schizophrenia, and COPD, the treatment record directed staff to change and date the oxygen tubing monthly and to cleanse and change the oxygen concentrator filter monthly. During observation, the oxygen tubing and humidified water bottle were both dated 5/23/25, and the filters were covered in gray lint. Staff interviews indicated the tubing and filter were supposed to be changed and cleaned every Sunday night on the night shift. The resident’s care plan also showed the resident wore oxygen at 2L/NC at all times and 3L/NC at bedtime. For another resident who was severely cognitively impaired and had shortness of breath at rest, with diagnoses including cancer, kidney disease, coronary artery disease, pneumonia, and malnutrition, the record showed oxygen therapy was in use, but there was no physician order for oxygen in the medical record and no care plan documentation regarding oxygen therapy. Observation showed an oxygen concentrator operating in the room, and the tubing into the concentrator was dated 7/14/25 as the last date cleaned and changed. A third resident with COPD and dependence on supplemental oxygen had orders for weekly oxygen tubing, humidifier, and filter changes, but observations showed no filter on the oxygen concentrator on two separate occasions.
Expired and Improperly Labeled Medications Found in Medication Room and Cart
Penalty
Summary
Drugs and biologicals were not stored and labeled in accordance with accepted professional principles when expired and improperly identified medications were found in the medication room and in a nurse/CMT medication cart. In the medication room, surveyors observed one opened vial of Tuberculin purified protein derivative dated 6/13/25 even though the box label stated it was good for 30 days after opening, and 11 Fluzone High Dose influenza vaccine prefilled syringes that had expired in 6/25. A CMT stated he/she did not know how long the TB vial was good for after opening and was not sure when the flu vaccine expired. In the South CMT/Nurse medication cart, surveyors observed Latanoprost eye drops with no opening date, a plastic bag with the label torn off containing two ondansetron tablets, Resident #23’s opened bottle of lidocaine viscous solution 2% that had expired in June 2025, an albuterol sulfate inhalation aerosol opened on 11/24/23 that lacked a pharmacy label identifying the resident and had been altered with tape and a handwritten name for Resident #32 on a box labeled for Resident #31, and an opened bottle of MOM that had expired in 5/25. The CMT stated he/she did not know who some of the medications belonged to, said all medications should have a pharmacy label, and stated expired medications should not be used and should be destroyed. An LPN and the ADON also stated medications should be dated when opened, expired medications should not be used, and TB should be discarded after 30 days.
Food Storage, Sanitation, and Hand Hygiene Deficiencies
Penalty
Summary
Food was not stored, prepared, distributed, and served in accordance with professional standards when expired leftovers were found in the refrigerator, food items were stored improperly, and kitchen sanitation and hand hygiene practices were not maintained. The facility’s policies required clean food storage areas, covered and dated refrigerated and frozen foods, proper separation of raw and ready-to-eat foods, and handwashing when entering the kitchen and when changing gloves. During observations, staff were seen serving resident trays without sanitizing hands between residents, and a staff member entered the kitchen, put on gloves without washing hands, and later changed gloves without washing hands after handling frozen strawberries. Multiple storage areas contained food and equipment that were dirty, moldlike, rusted, unlabeled, undated, or expired. In the dry storeroom, surveyors observed marshmallows on the floor, moldlike substance on a cup cart and on the floor, moldlike growth on a syrup container and on the wall near the floor, rusted shelving, an unsealed beef flavor soup base, beans in an unsealed unlabeled undated container, expired breadcrumbs, unlabeled cereal, a gelatin mix package with no date and moldlike growth, a rusted cherry pie filling can, debris near a bait trap, resealed yeast, an open bag of grain in a trash can, dirt on a hash browns container, and a moving cart covered in moldlike substance. In the dishwashing area, the vent duct was covered in grime and there was heavy grime and food buildup under the dishwasher. The walk-in refrigerator also contained multiple sanitation and storage issues, including rotten vegetables on the floor, a dried milk stain under shelving, defrosting beef with no date, expired cottage cheese and sour cream, condensation puddles, a box of milk shakes stored on the floor, undated apple crisp, expired hot dog buns and English muffins, moldy cucumbers, and expired coffee cake. The walk-in freezer had a condenser leak that caused ice buildup on the floor and chunks of ice on the floor. The dining room refrigerator had food stains on the inside shelving, and the ice machine had dirt buildup and a cleaning log showing the last cleaning date as 4/26/24. Staff and management acknowledged that expired products should be discarded, meat being defrosted should be dated, items should not be stored on the floor, and staff entering the kitchen should wash their hands immediately.
Incomplete PBJ Staffing Submission and Missing RN Coverage
Penalty
Summary
The facility failed to submit complete and accurate PBJ staffing information for Quarter 2 2025 based on payroll and other verifiable and auditable data. Review of the PBJ submission showed no RN coverage hours on 2/23, 3/2, 3/16, 3/29, and 3/30, and no licensed nurse on 1/25, 2/11, 3/13, and 3/29. Staffing schedules also showed no RN on 2/23, 3/2, 3/16, 3/29, and 3/30, and the facility did not provide a PBJ policy. During interviews, the Regional Nurse stated something was not right with the PBJ and did not think it had been filled out correctly. The ADON said the facility could not find documentation showing RN coverage on the listed dates, provided documentation showing a licensed nurse on the indicated dates, and stated the facility had a rough time with staffing early in the year. The Administrator stated the PBJ report should be filled out correctly and that the facility should have an RN working eight hours a day, seven days a week.
Failure to Follow Hearing Aid Care Plan
Penalty
Summary
The facility failed to follow care plan directions for maintaining and using hearing aids for a resident with a documented hearing deficit. The resident's quarterly MDS showed severe cognitive impairment, moderate difficulty hearing without a hearing aid, and that the resident usually understands verbal content but misses some part or intent of the message. The resident also had diagnoses including cancer, kidney disease, coronary artery disease, pneumonia, and malnutrition. The care plan, revised 6/30/25, identified a communication problem related to hearing deficit and directed staff to ensure bilateral hearing aids were available, functioning, fully charged, and in place. During observation, the resident was very hard of hearing and staff had to speak directly and loudly for the resident to understand. The resident stated that he/she should have two hearing aids but did not know where they were and was unsure whether any hearing aids were present. CNA and RN interviews indicated the resident did not have hearing aids and that staff could not find any in the room. The DON stated the resident did not like the hearing aids and staff had trouble getting the resident to wear them, while also stating the ADON knew exactly what happened to the hearing aids and that hearing aids and any changes in their use should be reflected in the care plan. The ADON later said she was not familiar with whether the resident had hearing aids, and the Administrator stated hearing aids should be care planned and staff should follow those directions.
Failure to Update Fall Interventions and Risk Assessment
Penalty
Summary
The facility failed to provide an environment free from accident hazards when staff did not implement new fall-prevention interventions for a resident who was at risk for falls and had experienced multiple falls. Resident #3 was admitted with diagnoses including non-traumatic brain dysfunction, cancer, anxiety, arthritis, and dementia, and later had significant memory problems, dependence on staff for many activities of daily living, substantial to maximum assistance needs for transfers, frequent bowel and bladder incontinence, and two or more falls with no injury plus one fall with a minor injury. The resident’s record showed repeated falls and related events, including being found on the floor, stumbling and falling backward, slipping out of bed, and multiple additional falls over several weeks. One fall resulted in head pain, swelling, bruising, confusion, lethargy, inability to bear weight, and transfer to the local hospital. Although a fall risk assessment dated 5/25/25 showed the resident scored 20, a later fall risk assessment dated [DATE] showed a score of 9, and another dated 7/28/25 again showed a score of 20. The care plan identified the resident as high risk for falls and listed interventions such as call light use, prompt response, non-skid socks, PT evaluation, and review of prior falls, but the care plan was not updated with new interventions after each fall. During interview, the DON stated fall interventions should be developed and added to the care plan and that the fall risk should be updated after each new fall.
Failure to Provide Timely Pain Management for Resident
Penalty
Summary
The facility failed to provide appropriate pain management for a resident who was admitted following a vehicle accident. Upon admission, the resident, who had undergone recent orthopedic surgery and was dependent on a walker and wheelchair, did not receive any pain medications for the first 48 hours. The resident's care plan indicated a need for oxycodone to alleviate pain, but the medication was not administered due to pending orders in the electronic medical record system. Interviews with staff revealed that the resident was in significant pain and experienced high anxiety due to the lack of medication. The resident's pain was described as sharp, aching, and radiating, with a pain score of 8 on a scale of 1 to 10. Despite multiple attempts by nursing staff to contact the primary care provider, Director of Nursing, and pharmacy, the resident's pain medication was not delivered until two days after admission. The deficiency was further compounded by communication breakdowns and procedural lapses. Staff members reported that the medication orders were not processed in a timely manner, and the facility's emergency medication kit did not contain the necessary narcotic pain medication. The Director of Nursing and Administrator were not adequately informed of the situation, leading to a delay in addressing the resident's pain management needs.
Improper Cleaning and Storage of Nebulizer Equipment
Penalty
Summary
The facility failed to ensure proper cleaning and storage of nebulizer equipment for a resident with respiratory issues, leading to potential contamination. The facility's policy required that nebulizer tubing and mouthpieces be cleaned, air-dried, and stored in a plastic bag marked with the date and resident's name. However, observations revealed that the nebulizer tubing and mouthpiece were left attached and placed on the resident's bed without being cleaned or stored properly. Interviews with staff confirmed that the equipment should have been cleaned and stored correctly, but this procedure was not followed. The resident involved had a history of chronic obstructive pulmonary disease, dyspnea, and mild intermittent asthma, and was receiving daily nebulizer treatments. Despite the facility's policy and staff awareness of the correct procedures, the nebulizer equipment was repeatedly observed inappropriately stored on the resident's bed. Staff interviews indicated that the cleaning and storage steps were overlooked, leading to the deficiency noted in the report.
Delayed Return of Resident Funds Post-Discharge
Penalty
Summary
The facility failed to provide personal funds and a final accounting within thirty days upon discharge for two residents. According to the facility's policy, funds should be conveyed within 30 days to the resident, their legal representative, or the individual administering the resident's estate. However, the facility's interim aging report showed that two residents had remaining balances in the facility's operating account after their discharge. The Business Office Manager (BOM) submitted invoices to the corporate office for refunds, but the checks were not processed and signed in a timely manner. The BOM submitted the invoices for the residents' refunds on the same day, but the corporate office delayed printing and signing the checks. For one resident, a check was printed but not signed, and for the other, no check was received. The BOM contacted the corporate office regarding the unsigned check, but as of the date of the interview, the issue remained unresolved. The facility's administrator acknowledged that the staff submitted the invoices on time, but the corporate office failed to issue the checks within the required 30-day period, leading to the deficiency.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
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 23 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) |
|---|---|---|---|---|
| Parkdale Manor Health & Rehabilitation | 4.1 mi | ★★★★★ | 1 | 0 |
| Village Care Center Inc | 5.1 mi | ★★★★★ | 1 | 0 |
| Maryville Living Center | 5.3 mi | ★★★★★ | 5 | 0 |
| Tiffany Heights | 20 mi | ★★★★★ | 15 | 0 |
| Pine View Manor Inc | 24.5 mi | ★★★★★ | 1 | 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.