Deficiencies (last 5 years)
Deficiencies (over 5 years)
2.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
49% better than Missouri average
Missouri average: 5.5 deficiencies/yearDeficiencies per year
8
6
4
2
0
Occupancy
Latest occupancy rate
32% occupied
Based on a September 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Plan of Correction
Census: 16
Deficiencies: 4
Date: Sep 23, 2025
Visit Reason
The document is a Statement of Deficiencies and Plan of Correction for Maple Tree Terrace Assisted Living following a survey completed on 09/23/2025. It addresses regulatory noncompliance related to tuberculosis screening, individualized service plans, and proper care per individual service plans.
Findings
The facility failed to ensure timely two-step tuberculosis screening for staff, did not develop complete individualized service plans for residents, and failed to provide proper care per individualized service plans including wound care, nail care, and compression wrapping. Policies were lacking and documentation was incomplete.
Deficiencies (4)
19 CSR 30-86.047(19) TB Screen Residents & Staff: The facility failed to ensure the required two-step tuberculosis screening test was administered timely for one of two sampled staff members. The facility census was 16.
19 CSR 30-86.047(28)(G) Individual Service Plan - Develop: The facility failed to develop a complete individualized service plan for one of three residents sampled. The facility census was 16.
19 CSR 30-86.047(28)(H) Individual Service Plan - Review Requirements: The facility failed to review the individualized service plan at least annually for two residents. The facility census was 16.
19 CSR 30-86.047(36) Proper Care Per Individual Service Plan: The facility failed to ensure all residents received proper care per their individualized service plan, including wound care, nail care, and compression wrapping for one resident. The facility census was 16.
Report Facts
Facility census: 16
Inspection Report
Plan of Correction
Census: 12
Deficiencies: 1
Date: Dec 5, 2023
Visit Reason
The inspection was conducted to investigate compliance with employment disqualification list (EDL) checks for newly hired staff prior to allowing contact with residents.
Findings
The facility failed to document EDL checks for four newly hired staff members before their start dates. The facility census was 12 at the time of inspection.
Deficiencies (1)
19 CSR 30-86.047(13)(B) EDL Inquiry: Facility staff failed to document a check of the employee disqualification list for four newly hired staff members prior to resident contact. The facility did not provide a policy regarding completion of EDL checks.
Report Facts
Facility census: 12
Number of newly hired staff without documented EDL checks: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| DON A | Director of Nursing | Named in deficiency for failure to document EDL check |
| Dietary B | Named in deficiency for failure to document EDL check | |
| CMA C | Certified Medication Aide | Named in deficiency for failure to document EDL check |
| CMA D | Certified Medication Aide | Named in deficiency for failure to document EDL check |
Inspection Report
Plan of Correction
Census: 13
Deficiencies: 2
Date: Sep 26, 2023
Visit Reason
The inspection was conducted to assess compliance with fire alarm system regulations and to document deficiencies related to fire alarm faults and maintenance.
Findings
The facility failed to correct faults in the fire alarm system and failed to test and maintain the complete fire alarm system as required. These deficiencies potentially affected all thirteen residents present during the inspection.
Deficiencies (2)
19 CSR 30-86.022(9)(B)(1)(B) Alarm/Detectors-Correct Faults: The facility failed to correct a fault in the fire alarm system, evidenced by a trouble light and failure to fix the alarm system.
19 CSR 30-86.022(9)(C) Fire Alarm System-Test/Maintain: The facility failed to test and maintain the complete fire alarm system in accordance with NFPA 72, 1999 edition.
Report Facts
Facility census: 13
Deficiencies cited: 2
Inspection Report
Plan of Correction
Census: 11
Deficiencies: 1
Date: Sep 29, 2022
Visit Reason
The inspection was conducted to investigate compliance with emergency discharge regulations following a specific resident discharge incident.
Findings
The facility failed to provide a written notice of discharge to a resident and their legally authorized representative when the resident could not be accepted back after a hospital stay due to inability to provide the required level of care. The resident was discharged without a discharge letter, and the facility could not handle the resident's higher level of care needs.
Deficiencies (1)
19 CSR 30-88.010(18) Emergency Discharges: The facility did not provide a written notice of discharge to Resident #1 and their legally authorized representative when the resident could not be accepted back after a hospital stay due to care level needs.
Report Facts
Facility census: 11
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | DON | Documented resident hospital admission and communication with hospital and family |
| Administrator | Administrator | Informed family about resident discharge and facility care limitations |
| Executive Director | Executive Director | Interviewed regarding discharge procedures and resident status |
Inspection Report
Life Safety
Census: 19
Deficiencies: 5
Date: Sep 8, 2021
Visit Reason
The inspection was a fire safety inspection conducted to assess compliance with fire alarm system installation, maintenance, smoke section partitions, and sprinkler system inspections.
Findings
The facility failed to properly install and maintain a complete fire alarm system, did not ensure smoke sections were properly separated by fire-rated partitions, and failed to maintain the sprinkler system with required inspections and certifications. These deficiencies potentially affected all nineteen residents present during the inspection.
Deficiencies (5)
19 CSR 30-86.022(9)(A) Fire Alarm Complete System. The facility failed to properly install a complete fire alarm system in accordance with NFPA 72, 1999 edition. Fire alarm wire splices were found above the ceiling of the med room access.
19 CSR 30-86.022(9)(A) Fire Alarm Complete System. Wire terminals, terminal boxes, splices, and joints did not conform to NFPA 70 National Electrical Code. The Executive Director was unaware of these open splices and will have them fixed.
19 CSR 30-86.022(9)(C) Fire Alarm System-Test/Maintain. The facility failed to test and maintain the complete fire alarm system as required by NFPA 72, 1999 edition. No documentation was provided for the semi-annual fire alarm inspection; last inspection was October 14, 2019.
19 CSR 30-86.022(10)(I) Smoke Section Partitions > than 20 beds. The facility failed to ensure each smoke section was separated by a one-hour fire-rated smoke partition extending from inside to outside walls and floor to roof deck. Several penetrating holes were found that would allow smoke, fire, and toxic gases to travel.
19 CSR 30-86.022(11)(F) Sprinkler Systems-Inspections, Cert. The facility failed to maintain the sprinkler system with required inspections and certifications per NFPA 25, 1998 edition. Annual fire sprinkler inspection reports showed missing internal pipe inspections and outdated gauge calibrations.
Report Facts
Facility census: 19
Deficiencies cited: 5
Inspection Report
Plan of Correction
Census: 29
Deficiencies: 1
Date: Sep 19, 2019
Visit Reason
The inspection was conducted to assess compliance with tuberculosis screening requirements for residents and staff at the assisted living facility.
Findings
The facility failed to ensure required two-step tuberculosis screening tests were completed for two staff members. The Administrator acknowledged the missed second step of TB testing for one staff member.
Deficiencies (1)
19 CSR 30-86.047(19) TB Screen Residents & Staff. The facility failed to ensure the required two-step tuberculosis screening tests were completed for two staff members out of a sample of four staff. One staff member missed the second step of the TB test.
Report Facts
Facility census: 29
Deficiency cited: 1
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