Inspection Reports for
Avalon View Health and Wellness
1200 WEST COLLEGE ST, LIBERTY, MO, 64068-1036
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
17.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
222% worse than Missouri average
Missouri average: 5.5 deficiencies/yearDeficiencies per year
28
21
14
7
0
Census
Latest occupancy rate
118 residents
Based on a November 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy over time
Inspection Report
Routine
Census: 118
Deficiencies: 1
Date: Nov 20, 2025
Visit Reason
The inspection was conducted to evaluate the facility's infection prevention and control program, specifically regarding the management and prevention of scabies spread among residents on the special care unit.
Findings
The facility failed to implement contact precautions and infection control measures for three residents diagnosed with scabies, resulting in prophylactic treatment of all residents on the special care unit. Staff were unaware or did not follow proper isolation and PPE protocols despite documented scabies cases and physician orders.
Deficiencies (1)
Failure to follow facility policy and physician orders to implement contact precautions and infection control measures to prevent the spread of scabies for three sampled residents.
Report Facts
Residents treated prophylactically: 30
Facility census: 118
Ivermectin dosage: 18
Dates of Ivermectin doses: 11
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Reported progress notes stating residents were not contagious and no precautions were put in place; involved in dermatology follow-up. |
| Assistant Director of Nursing | Assistant Director of Nursing (ADON) | Stated residents with scabies should be isolated and on contact precautions. |
| Certified Medication Technician A | Certified Medication Technician (CMT) A | Observed holding hand of resident with rash without PPE and unaware of scabies diagnosis. |
| Certified Medication Technician B | Certified Medication Technician (CMT) B | Unaware of residents diagnosed with scabies; described PPE use if resident had scabies. |
| Certified Medication Technician C | Certified Medication Technician (CMT) C | Unaware of residents diagnosed with scabies; described PPE use if resident had scabies. |
| Registered Nurse A | Registered Nurse (RN) A | Stated residents diagnosed with scabies would be placed on contact precautions. |
| Nursing Assistant A | Nursing Assistant (NA) A | Unaware of cause or contagiousness of residents' rashes. |
| Certified Nursing Assistant A | Certified Nursing Assistant (CNA) A | Uncertain about cause and contagiousness of residents' rashes. |
| LPN A | Licensed Practical Nurse (LPN) A | Not aware of scabies outbreak on memory care unit. |
| LPN B | Licensed Practical Nurse (LPN) B | Had not been notified of scabies outbreak or concerns. |
| Medical Assistant A | Medical Assistant (MA) A | Stated residents treated for scabies needed isolation and contact precautions. |
| Dermatology Physician Assistant | Physician Assistant (PA) | Provided diagnosis and treatment recommendations for residents with scabies; expected contact precautions. |
| Administrator | Administrator | Reported treatment of residents and staff member with permethrin without confirmed diagnosis. |
Inspection Report
Complaint Investigation
Census: 111
Deficiencies: 1
Date: Sep 19, 2025
Visit Reason
The inspection was conducted due to a complaint investigation following an incident where a resident was injured during transportation in a facility vehicle because they were not properly restrained and supervised by the designated driver.
Complaint Details
The complaint investigation was substantiated. The resident slid out of the wheelchair during transport due to the driver not applying the seatbelt. The resident was assessed with no serious injury but some pain was reported. The driver was new to transportation duties and had not completed proper training prior to the incident. Corrective actions and re-education were implemented.
Findings
The facility failed to ensure the environment was free from accident hazards and did not follow its transportation policy, resulting in a resident sliding out of a wheelchair and sustaining minor injury during transport. Corrective actions included staff suspensions, re-education on transport safety, competency demonstrations, and implementation of audits and driving record validations.
Deficiencies (1)
Failed to ensure the environment was free from accident hazards and did not properly restrain and supervise a resident during transportation, resulting in injury.
Report Facts
Facility census: 111
Date of incident: Aug 25, 2025
Date of correction: Sep 2, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Employee #1 | Suspended pending investigation related to transportation incident | |
| Director of Maintenance | Suspended pending investigation and re-educated on transportation safety | |
| Administrator | Notified of noncompliance, oversaw corrective actions and staff re-education | |
| Licensed Practical Nurse (LPN) A | Licensed Practical Nurse | Documented resident's condition after the incident |
| Director of Nursing (DON) | Director of Nursing | Notified physician, monitored resident post-incident, and provided interviews |
| Transportation Driver | New transportation driver involved in the incident, received training and competency demonstration after the incident | |
| Regional Maintenance | Conducted training and competency checks for transportation driver after incident |
Inspection Report
Routine
Census: 111
Deficiencies: 2
Date: Sep 19, 2025
Visit Reason
The inspection was conducted to assess compliance with residents' rights regarding treatment, advanced directives, and the proper invocation of Durable Power of Attorney (DPOA) for medical decision-making in the facility.
Findings
The facility failed to ensure staff invoked the Durable Power of Attorney prior to allowing designated agents to make medical decisions for residents. Additionally, two residents were declared incapacitated by two physicians but had no guardianship or DPOA in place. This affected seven of eleven sampled residents.
Deficiencies (2)
Failure to ensure staff invoked Durable Power of Attorney before allowing designated agents to make medical decisions.
Failure to ensure two residents had designated individuals to make medical decisions when declared incapacitated by two physicians.
Report Facts
Residents affected: 7
Facility census: 111
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Physician A | Signed Certificate of Capacity for Resident #33 on 7/7/2021. | |
| Physician B | Signed Certificate of Capacity for Resident #33 on 8/22/2021 and Resident #48 on 6/6/2021. | |
| Physician C | Signed Certificate of Capacity for Resident #48 on 5/28/2021. | |
| Social Services Designee | Interviewed on 9/19/2025 regarding awareness of DPOA invocation issues. | |
| Administrator | Interviewed on 9/19/2025 regarding awareness of residents' medical decision-making and DPOA invocation. |
Inspection Report
Complaint Investigation
Census: 108
Deficiencies: 1
Date: Apr 2, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding a resident-to-resident physical abuse incident where Resident #2 hit Resident #1 in the back.
Complaint Details
The complaint investigation found that Resident #2 hit Resident #1 on the back on 3/24/25. Both residents were assessed; Resident #1 had redness on the back, Resident #2 had no injuries. Both residents reported feeling safe. The facility conducted an investigation, notified responsible parties, implemented environmental changes, provided trauma-informed care, reviewed medications, updated care plans, and provided staff education on de-escalation and abuse prevention.
Findings
The facility failed to protect Resident #1 from physical abuse by Resident #2, resulting in redness on Resident #1's back. The facility promptly investigated, implemented corrective actions, and updated care plans and staff education to prevent recurrence.
Deficiencies (1)
Failed to protect a resident from physical abuse by another resident resulting in redness to the resident's back.
Report Facts
Census: 108
Date of incident: Mar 24, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CMT A | Certified Medication Technician | Reported and intervened in the resident-to-resident altercation |
| LPN A | Licensed Practical Nurse | Assessed residents after the altercation and notified Director of Nursing and physician |
| Administrator | Provided background information on residents and facility response |
Inspection Report
Routine
Census: 104
Deficiencies: 4
Date: Sep 23, 2024
Visit Reason
The inspection was conducted to assess compliance with regulations related to resident privacy, housekeeping and maintenance, activities programming, and nursing staffing adequacy at Avalon View Health and Wellness.
Findings
The facility failed to maintain confidentiality of resident records, ensure a safe and clean environment, provide adequate activities programming for residents, and maintain sufficient nursing staff to meet residents' basic care needs including hygiene, toileting, and timely call light response.
Deficiencies (4)
Failed to ensure confidentiality of resident records for two residents when DPOA paperwork was given to an unauthorized person and medication packaging with personal information was found outside the facility.
Failed to maintain a safe, clean, and homelike environment including housekeeping and maintenance issues such as strong urine odor, peeling baseboards, torn wheelchairs, stained privacy curtains, dirty dishes, and dead bugs in sanitizer dispensers.
Failed to provide an ongoing activities program to meet the needs of three residents, including lack of individualized care plans and insufficient engagement.
Failed to provide sufficient nursing staff to meet basic care needs for seven residents including assistance with repositioning, incontinent care, hygiene, bathing, and timely response to call lights.
Report Facts
Facility census: 104
Residents sampled: 21
Residents affected by confidentiality deficiency: 2
Residents affected by housekeeping deficiency: 104
Residents affected by activities deficiency: 3
Residents affected by staffing deficiency: 7
Residents in Resident Council interviewed: 20
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN B | Licensed Practical Nurse | Mentioned in relation to failure to provide incontinent care and expectations for toileting every two hours |
| CNA D | Certified Nursing Assistant | Mentioned in relation to failure to provide incontinent care and staffing shortages |
| CNA A | Certified Nursing Assistant | Mentioned regarding staffing shortages and inability to complete all patient care needs |
| CMT A | Certified Medication Technician | Mentioned regarding staffing shortages impacting medication passes and showers |
| RN A | Registered Nurse | Mentioned regarding staffing shortages and impact on resident care |
| Director of Nursing | Director of Nursing | Mentioned regarding staffing challenges and inability to control staff call outs |
| Administrator | Facility Administrator | Mentioned regarding expectations for confidentiality, cleanliness, activities, and staffing goals |
| Physical Therapy Assistant A | Physical Therapy Assistant | Mentioned regarding wheelchair replacement needs |
| Director of Physical Therapy | Director of Physical Therapy | Mentioned regarding wheelchair orders and maintenance |
| Housekeeper A | Housekeeper | Mentioned regarding cleaning duties and workload |
| Housekeeping Supervisor | Housekeeping Supervisor | Mentioned regarding cleaning expectations |
| Maintenance Director | Maintenance Director | Mentioned regarding repairs and cleaning responsibilities |
| Activities Director | Activities Director | Mentioned regarding activities programming and care planning |
| MDS Coordinator | MDS Coordinator | Mentioned regarding care plan documentation |
Inspection Report
Routine
Census: 104
Deficiencies: 17
Date: Sep 23, 2024
Visit Reason
Routine inspection of Avalon View Health and Wellness to assess compliance with healthcare facility regulations including resident rights, care, safety, and environment.
Findings
The facility had multiple deficiencies including failure to treat residents with dignity and respect, inadequate access to personal funds, inconsistent code status documentation, breaches in confidentiality, unsanitary environment and equipment, incomplete care plans, insufficient assistance with activities of daily living, lack of trauma informed care, insufficient staffing impacting resident care, medication management issues, food service deficiencies, and environmental safety hazards.
Deficiencies (17)
Failure to treat residents with dignity and respect including inadequate clothing and hygiene assistance.
Failure to ensure residents had access to personal funds after business hours and on weekends.
Inconsistent documentation of resident code status across clinical records.
Breach of confidentiality with unauthorized release of resident durable power of attorney documents and exposure of personal medication information.
Unsanitary conditions and disrepair in facility environment including urine odor, peeling baseboards, torn wheelchairs, stained curtains, dirty dishes, and dead bugs.
Incomplete and inadequate comprehensive care plans for residents with complex needs including lack of activity preferences and tracheostomy care plans.
Failure to provide adequate assistance with grooming, bathing, incontinent care, and showering for multiple residents.
Failure to provide trauma informed care including identification and mitigation of triggers for residents with PTSD and other trauma histories.
Insufficient nursing staff to meet resident care needs including toileting, repositioning, feeding, and showering.
Failure to store and label medications properly, including unlocked medication carts, expired medications, and medications left at bedside without orders.
Inadequate dietary staffing resulting in delayed meal service and insufficient assistance to residents during meals.
Food served was often cold, unpalatable, not prepared according to recipes, and served without proper temperature checks or utensils.
Failure to properly clean and sanitize kitchen equipment and maintain a sanitary kitchen environment including dirty floors, vents, equipment, and improper hand hygiene by staff.
Failure to wear appropriate hair and beard coverings by kitchen staff.
Failure to label and date food items in storage and maintain proper food storage practices.
Facility environment not maintained in a safe, clean, and comfortable condition with issues including cobwebs, dead bugs, peeling wallpaper, broken blinds, dirty vents, and damaged fixtures.
Ineffective pest control program with presence of flies and roaches in resident rooms and common areas.
Report Facts
Facility census: 104
Shower opportunities received: 7
Shower opportunities received: 8
Medication cart temperature: 105.8
Medication cart temperature: 160
Meal service delay: 69
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA A | Certified Nurse Aide | Named in shower and incontinent care deficiencies, and trauma trigger observations |
| LPN B | Licensed Practical Nurse | Named in incontinent care deficiencies and medication cart observations |
| CMT A | Certified Medication Technician | Named in medication cart and trauma trigger observations |
| Cook A | Cook | Named in food preparation deficiencies |
| Dietary Manager | Named in food service and kitchen sanitation deficiencies | |
| Registered Dietician | Named in food service deficiencies and expectations | |
| Housekeeper A | Named in facility cleanliness deficiencies | |
| Maintenance Director | Named in facility maintenance and cleanliness deficiencies | |
| Administrator | Named in multiple deficiencies and expectations | |
| Director of Nursing | Named in multiple deficiencies and expectations | |
| Social Services Director | Named in trauma informed care deficiencies |
Inspection Report
Routine
Census: 82
Deficiencies: 4
Date: Feb 12, 2024
Visit Reason
The inspection was conducted to assess the facility's compliance with resident rights, safety, hygiene, and environmental standards, including call light accessibility, personal dignity, cleanliness, and assistance with activities of daily living.
Findings
The facility failed to ensure call lights were within reach and responded to timely, moved residents' personal belongings without permission, maintained a clean environment, and provided adequate assistance with dressing, grooming, and bathing for several residents. Multiple residents reported unmet needs and dissatisfaction with care.
Deficiencies (4)
Failure to ensure call lights were within reach and timely response to call lights for multiple residents.
Failure to respect residents' personal belongings by moving items without permission.
Failure to maintain a clean and comfortable homelike environment with dirt, food debris, and trash on floors and surfaces.
Failure to provide adequate dressing, shaving, grooming, and bathing assistance to residents as per care plans and preferences.
Report Facts
Residents affected: 7
Sampled residents: 28
Sampled residents: 26
Facility census: 82
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA A | Certified Nurse Aide | Interviewed regarding call light issues and staff responsibilities |
| CNA B | Certified Nurse Aide | Interviewed regarding moving resident belongings without permission |
| CMT A | Certified Medication Technician | Interviewed about call light policies and shower assistance |
| CMT C | Certified Medication Technician | Interviewed about shower assistance and staffing issues |
| CNA K | Certified Nurse Aide | Interviewed about shower scheduling and staffing |
| Administrator | Facility Administrator | Interviewed about call light policies, resident rights, and shower expectations |
| Director of Nursing | Director of Nursing (DON) | Interviewed about shower schedules, refusals, and care plan updates |
Inspection Report
Annual Inspection
Census: 82
Deficiencies: 3
Date: Dec 14, 2023
Visit Reason
The inspection was conducted to assess compliance with resident rights, dignity, call light accessibility, and the maintenance of a safe, clean, and homelike environment at Avalon View Health and Wellness.
Findings
The facility failed to ensure residents' dignity by not keeping call lights within reach, delayed response to call lights, and moving residents' personal belongings without their presence. Additionally, the facility did not maintain a clean and comfortable environment, with issues such as dirty rooms, stained furniture, unemptied trash, and leftover food trays left in hallways. These deficiencies affected multiple residents and posed minimal harm or potential for actual harm.
Deficiencies (3)
Staff did not ensure call lights were within reach for three residents and did not respond timely to call lights for one resident.
Staff moved two residents' personal belongings without them being present.
Facility failed to maintain a clean and comfortable homelike environment, including unclean resident rooms, stained furniture, unemptied trash, and leftover food trays in hallways.
Report Facts
Residents affected: 7
Residents affected: 8
Facility census: 82
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA A | Certified Nurse Aide | Mentioned in relation to call light monitoring and response |
| CMT A | Certified Medication Technician | Provided information on call light policy |
| Administrator | Provided statements on call light response and facility cleanliness expectations | |
| Director of Nursing | Discussed responsibility for cleanliness and dirty dishes | |
| Dietary Manager | Discussed issues with dirty dishes and meal tray management | |
| Housekeeper A | Discussed expectations for furniture cleanliness and food debris | |
| Housekeeper B | Discussed expectations for furniture cleanliness and food debris | |
| Licensed Practical Nurse G | Licensed Practical Nurse | Discussed expectations for furniture cleanliness and food debris |
Inspection Report
Routine
Census: 82
Deficiencies: 15
Date: Dec 14, 2023
Visit Reason
The inspection was conducted as a routine regulatory survey to assess compliance with healthcare facility regulations, including resident rights, safety, infection control, medication administration, and facility maintenance.
Findings
The facility was found deficient in multiple areas including failure to ensure residents' dignity and timely response to call lights, inadequate maintenance of a clean and homelike environment, incomplete criminal background checks for staff, lack of PASARR screening for residents with mental disorders, medication administration errors, inadequate assistance with activities of daily living, improper use and assessment of bed rails, insufficient RN coverage, delayed meal service, unsafe food handling and storage practices, and failure to maintain an effective infection prevention and control program.
Deficiencies (15)
Failure to ensure residents' dignity and timely response to call lights affecting seven residents.
Failure to maintain a clean and comfortable homelike environment affecting eight residents.
Failure to complete criminal background checks for three nursing staff employees.
Failure to complete PASARR screening for two residents with serious mental illness.
Failure to provide care and treatment in accordance with professional standards for medication administration for three residents.
Failure to provide bathing assistance and document showers for three dependent residents.
Failure to assess residents for risk of entrapment from bed rails prior to installation and failure to ensure scheduled maintenance and proper use of bed rails for four residents.
Failure to use the services of a registered nurse for at least eight consecutive hours a day, seven days a week.
Medication error rate of 8% due to failure to follow physician orders for medication administration affecting two residents.
Failure to ensure residents are free from significant medication errors affecting three residents.
Failure to provide annual dental exam and timely dental consult for one resident requesting dentures.
Failure to serve meals according to scheduled meal times affecting two residents.
Failure to prepare and serve food in accordance with professional food safety standards, including improper food storage, labeling, temperature monitoring, and hand hygiene.
Failure to maintain an infection prevention and control program including improper use of PPE, lack of doffing containers, and failure to isolate COVID-19 positive residents properly affecting three residents.
Failure to maintain the building in good repair including damaged furniture, broken air conditioning units, cracked ceilings, and damaged exterior building components.
Report Facts
Residents affected: 7
Residents affected: 8
Residents affected: 3
Residents affected: 2
Residents affected: 3
Residents affected: 3
Residents affected: 4
Residents affected: 7
Medication error rate: 8
Residents affected: 3
Residents affected: 1
Residents affected: 2
Food safety violations: 15
Residents affected: 3
Facility maintenance issues: 7
Inspection Report
Complaint Investigation
Census: 85
Deficiencies: 2
Date: Jul 28, 2023
Visit Reason
The inspection was conducted due to complaints regarding the facility's failure to properly investigate and follow policy on resident to resident altercations, and concerns about maintaining a safe, functional, sanitary, and comfortable environment.
Complaint Details
The complaint investigation found that the facility did not properly investigate resident to resident altercations involving four residents, failed to interview other residents about their feelings of safety, and did not notify physicians or law enforcement as required. The facility also failed to maintain a safe environment with broken windows and unsecured air conditioning units.
Findings
The facility failed to conduct thorough investigations of resident to resident altercations, including not interviewing involved residents or notifying physicians and law enforcement. Additionally, the facility failed to maintain a safe environment by not replacing broken or missing window panes and leaving air conditioning units unsecured on the secure community.
Deficiencies (2)
Failure to conduct thorough investigations and follow policy on resident to resident altercations, including lack of interviews with involved residents and others, and failure to notify physician and law enforcement.
Failure to maintain a safe, functional, sanitary, and comfortable environment by not replacing broken or missing window panes and leaving air conditioning units unsecured.
Report Facts
Residents affected: 4
Facility census: 85
Broken window panes: 10
Physical altercation dates: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Social Worker | Interviewed on 7/28/23 regarding resident to resident altercations and investigation procedures. | |
| Administrator | Interviewed on 7/28/23 regarding awareness of investigation procedures and environmental safety issues. | |
| Certified Nurses Aide A | Interviewed on 7/27/23 about broken windows and air conditioning unit cover. | |
| Certified Medication Technician A | Interviewed on 7/27/23 about broken windows. | |
| Maintenance Director | Interviewed on 7/28/23 about broken windows and air conditioning unit cover. |
Inspection Report
Complaint Investigation
Census: 85
Deficiencies: 2
Date: Jul 28, 2023
Visit Reason
The inspection was conducted due to complaints regarding the facility's failure to properly investigate and follow policy on resident-to-resident altercations involving four sampled residents, and concerns about maintaining a safe, functional, sanitary, and comfortable environment.
Complaint Details
The complaint investigation found that the facility did not properly investigate resident-to-resident altercations involving Residents #1, #2, #3, and #4, with missing interviews of involved residents and witnesses, and failure to notify physicians and law enforcement. The facility also failed to maintain a safe environment with broken windows and unsecured air conditioning units.
Findings
The facility failed to conduct thorough investigations of resident-to-resident altercations, including inadequate interviews of involved residents and witnesses, and failure to notify physicians or law enforcement. Additionally, the facility failed to maintain a safe environment by not replacing broken or missing window panes and not securing air conditioning unit covers on the secure community.
Deficiencies (2)
Failed to conduct thorough investigations and follow policy on resident-to-resident altercations, including lack of interviews with involved residents, witnesses, and failure to notify physician or law enforcement.
Failed to maintain a safe, functional, sanitary, and comfortable environment by not replacing broken/missing window panes and not securing air conditioning unit covers on the secure community.
Report Facts
Residents involved in altercations: 4
Facility census: 85
Dates of altercations: July 20, 2023; July 21, 2023; July 22, 2023; July 24, 2023; July 25, 2023
Broken window coverage duration: 2
Number of broken/missing window panes: Multiple broken/missing panes in rooms E11, E12, E13, and E20
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Social Worker | Interviewed regarding resident-to-resident altercation investigations and resident interviews | |
| Administrator | Interviewed regarding awareness of investigation procedures and environmental safety issues | |
| Certified Nurses Aide A | Interviewed about broken windows and air conditioning unit cover | |
| Certified Medication Technician A | Interviewed about broken windows | |
| Maintenance Director | Interviewed about broken windows and air conditioning unit cover |
Inspection Report
Census: 84
Deficiencies: 1
Date: May 23, 2023
Visit Reason
The inspection was conducted to assess the facility's maintenance of a safe, clean, and comfortable environment, specifically focusing on the condition of the facility grounds and lawn maintenance.
Findings
The facility failed to maintain the grounds properly, with grass approximately eighteen inches tall and overgrown due to lapses in lawn maintenance services. Interviews confirmed the facility was between lawn service providers and lacked some equipment, such as a weedeater.
Deficiencies (1)
Facility grounds were not mowed; grass was headed out and approximately eighteen inches tall; grass was overgrown.
Report Facts
Days since last mowing: 10
Grass height in inches: 18
Facility census: 84
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator in Training (AIT) | Provided information about lawn maintenance responsibilities and schedule | |
| Maintenance Director | Provided information about lawn service status and mowing frequency |
Viewing
Loading inspection reports...
