Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 during CMS and state inspections, most recent first.
A resident with cardiovascular conditions and mild to moderate cognitive impairment received multiple incorrect medications when an LPN relied only on the resident’s verbal confirmation of identity and did not verify that the prepared medications were for the correct person. The LPN, who was managing three treatment carts, administered a combination of drugs including cardiac, pain, antibiotic, neurologic, and supplement medications intended for another individual. After receiving the wrong medications, the resident’s BP dropped, prompting transfer to the ER for evaluation, and facility leadership later acknowledged that the LPN failed to administer the correct medications.
Staff did not follow hand hygiene protocols during meal service, including failing to sanitize hands between resident contact and not cleaning the meal cart after removing dirty trays. Additionally, the facility lacked a water management program and had not conducted a risk assessment for water-borne pathogens, as confirmed by the administrator.
A dependent resident with dementia and cerebral atherosclerosis was observed on multiple occasions with significant chin hair and expressed a desire for staff assistance with shaving. Staff and the DNS acknowledged the resident's need for help with personal hygiene, but the required assistance was not provided.
A resident with dysphagia choked after a CNA left a meal tray unattended, contrary to the care plan requiring one-on-one assistance. The resident began eating alone and choked, but an OT in the room performed the Heimlich maneuver, resolving the situation. The facility's investigation confirmed the CNA's failure to follow the care plan.
Significant Medication Error Due to Failure to Verify Resident Identity
Penalty
Summary
The deficiency involves a failure to ensure that a resident was free from significant medication errors when an LPN administered a large number of incorrect medications to the resident. The resident had diagnoses including orthostatic hypotension and a prosthetic heart valve, with a care plan noting impaired and altered cardiovascular function due to a pacemaker, and an MDS BIMS score of 12/15 indicating mild to moderate cognitive impairment. On the identified date, the facility’s risk management report documented that the LPN wrongly administered a combination of multiple medications, including Levothyroxine, Tylenol, Gabapentin, Bactrim, Amiodarone, Baclofen, Calcium Citrate with Vitamin D3, Clopidogrel, CoQ10, Entresto, Finasteride, a multivitamin, Torsemide, and Ezetimibe to this resident. According to the LPN’s own account, she asked the resident if they were the intended individual, accepted the resident’s verbal confirmation, and proceeded to give the medications without verifying that the medications prepared were for the correct resident. She reported that she did not check to ensure the medications matched the correct resident and attributed the error to an unstructured medication system and being assigned to manage three different treatment carts during her shift. Following administration of the wrong medications, the resident experienced a change in condition, including a drop in blood pressure to 99/49, as documented in the nursing progress note, and was sent to the emergency room for evaluation. The administrator and DNS acknowledged that the LPN failed to administer the correct medications to the resident.
Deficiencies in Hand Hygiene During Meal Service and Lack of Water Management Program
Penalty
Summary
Staff failed to follow proper hand hygiene protocols during meal service on one of six halls reviewed. Specifically, a nursing assistant did not sanitize a serving cart after removing dirty breakfast trays before loading it with lunch trays, nor did she perform hand hygiene between delivering trays to residents, assisting with repositioning, or after leaving resident rooms. The staff member acknowledged not sanitizing her hands or the cart as required by facility policy, which mandates hand hygiene before and after resident contact, after touching objects in the resident's vicinity, and before and after handling food or assisting with meals. The Director of Nursing Services confirmed the expectation for staff to perform hand hygiene after each tray pass and to sanitize the meal cart before each use. Additionally, the facility did not have a developed or implemented water management program to address the risk of water-borne pathogens, such as Legionella, in the main water system. Although the facility had a Legionella Water Management Policy stating the need for annual review and risk assessment, there was no evidence of a risk assessment being completed as part of the facility's assessment. The administrator confirmed the absence of a water management program or prevention plan for water-borne pathogens in the facility's water system.
Failure to Provide Required Assistance with Personal Hygiene
Penalty
Summary
A resident with diagnoses of cerebral atherosclerosis and dementia, admitted in August 2024, was identified as being dependent on staff for personal hygiene and grooming according to a recent Significant Change MDS. On two separate observations, the resident was noted to have a significant amount of chin hair. The resident expressed a desire not to have facial hair and stated reliance on staff for shaving. Staff interviews confirmed awareness of the resident's need for assistance with shaving, and the Director of Nursing Services also acknowledged the resident's need for a shave during observation. Despite the resident's dependence and expressed wishes, staff failed to provide the necessary assistance with personal hygiene, specifically shaving, as required.
Failure to Follow Care Plan Leads to Choking Incident
Penalty
Summary
The facility failed to adhere to care plan interventions for a resident with dysphagia, leading to a choking incident. The resident, who was admitted with a traumatic subdural hemorrhage and difficulty swallowing, required one-on-one assistance during meals as per their care plan. However, a CNA delivered the resident's lunch tray and left it with the resident, intending to return after delivering other trays. The resident, who was cognitively intact, began eating without assistance and subsequently choked on the food. An occupational therapist present in the room was alerted by the resident's roommate and performed the Heimlich maneuver, successfully dislodging the food. The facility's investigation confirmed that the CNA did not follow the care plan, which specified that residents needing meal assistance should not be left alone with their trays. Observations conducted over several days following the incident did not identify further issues related to choking or aspiration risks.
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What surveyors actually found near you
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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.
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Illustrative
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Nursing homes near Beaverton
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Beaverton Post Acute Care Of Cascadia | 1.6 mi | ★★★★★ | 1 | 0 |
| Robison Jewish Health Center | 4.4 mi | ★★★★★ | 23 | 0 |
| Marquis Autumn Hills Memory Care | 4.4 mi | ★★★★★ | 7 | 0 |
| Marquis Vermont Hills | 4.4 mi | ★★★★★ | 2 | 0 |
| West Hills Health & Rehabilitation | 4.5 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.