Inspection Reports for
Maywood Terrace Living Center

MO, 64052

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3 Reports

2019–2025

Inspection Report — Mar 19, 2025

Routine
Date: Mar 19, 2025

Visit Reason
Federal health survey (CMS-2567) and Missouri State Form; the survey type is routine.

Findings
Two deficiencies were cited: one federal health citation and one Missouri State licensure citation. Both relate to medication control and administration practices, specifically failures to account for and properly document receipt and counts of controlled (narcotic) medications.

Deficiencies (1)
19 CSR 30-85.042(46) Safe/Effective Medication System: Refer to F761.
Report Facts
tablets of oxycodone: 120 residents sampled: 3

Inspection Report — Oct 9, 2020

Life Safety
Date: Oct 9, 2020

Visit Reason
Federal Life Safety (CMS-2567) survey and Missouri state licensure (State Form); survey type: life safety.

Findings
Ten deficiencies were cited: five federal life safety K-tag deficiencies concerning storage of hazardous materials, means of egress, emergency lighting, smoke barrier doors, and fire drills; and five Missouri state deficiencies concerning exit requirements, emergency lighting, smoke section walls/doors, fire drill records, and substantial construction/maintenance.

Deficiencies (5)
19 CSR 30-85.022(12) Exit Requirements: Refer to K211.
19 CSR 30-85.022(25) Emergency Lighting: Refer to K291.
19 CSR 30-85.022(29) Smoke Section Walls/Doors: Refer to K374.
19 CSR 30-85.022(33)(F) Fire Drill Records: Refer to K712.
19 CSR 30-85.032(2) Substantially Constructed/Maintained: Refer to K374.
Report Facts
buckets found: 2 residents potentially affected: 23 total smoke zones: 5

Inspection Report — Apr 25, 2019

Life Safety
Date: Apr 25, 2019

Visit Reason
Federal CMS-2567 Life Safety (K tags) and Emergency Preparedness (E tags) forms and Missouri Department of Health and Senior Services State Form were included; the survey is a life safety survey.

Findings
27 deficiencies were cited: 10 federal Life Safety K-tag deficiencies addressing building construction/smoke penetration, exit discharge/egress obstructions, emergency lighting, protection (lint buildup), cooking range hood nozzles, fire alarm/testing, portable fire extinguishers, corridor doors, smoke barriers and fire drills; 5 federal Emergency Preparedness E-tag deficiencies addressing emergency planning for patient populations, collaboration/contact information, subsistence needs, waiver/roles, and backup communications; and 12 Missouri state licensure deficiencies largely reflecting the same fire-safety and operational policy failures.

Deficiencies (12)
19 CSR 30-85.022(2)(E) No Fire Hazard: Refer to K300.
19 CSR 30-85.022(8)(D) Fire Extinguisher UL/FM, Monthly Check: Refer to K355.
19 CSR 30-85.022(9) Range Hood Certification: Refer to K324 and K355.
19 CSR 30-85.022(10)(B) Fire Alarm System-Test/Maintain: Refer to K345.
19 CSR 30-85.022(12) Exit Requirements: Refer to K271.
19 CSR 30-85.022(25) Emergency Lighting: Refer to K291.
19 CSR 30-85.022(29) Smoke Section Walls/Doors: Refer to K372.
19 CSR 30-85.022(34)(B)(1-10) Fire Safety Training Requirements-elements: Refer to K712.
19 CSR 30-85.032(2) Substantially Constructed/Maintained: Refer to K161, K271 and K363.
19 CSR 30-85.042(7) Written Agreement for Outside Resources: Refer to E15.
19 CSR 30-85.042(13) Policies/Procedures-Operational: Refer to E7, E9, E15, E26 and E32.
19 CSR 30-85.042(15) Personnel Informed of Policies/Duties: Refer to E7, E9, E15, E26 and E32.
Report Facts
residents potentially affected: 11 facility staff potentially affected: 7 residents potentially affected: 30 residents potentially affected: 35

9 CMS Surveys

Inspection Report — Mar 19, 2025

Routine
Date: Mar 19, 2025

Visit Reason
Federal health survey (CMS-2567) and Missouri State Form; the survey type is routine.

Findings
Two deficiencies were cited: one federal health citation and one Missouri State licensure citation. Both relate to medication control and administration practices, specifically failures to account for and properly document receipt and counts of controlled (narcotic) medications.

Deficiencies (1)
F 761 Label/Store Drugs and Biologicals: Based on interview and record review, the facility failed to properly account for the delivery of 120 tablets of Oxycodone 20 mg from the pharmacy for one sampled resident and narcotic counts and documentation were not consistently completed by two staff as required.
Report Facts
tablets of oxycodone: 120 residents sampled: 3

Inspection Report — Jul 16, 2024

Routine
Date: Jul 16, 2024

Visit Reason
The inspection was conducted as a routine regulatory survey to assess compliance with healthcare facility regulations, including resident care, medication management, infection control, staffing, and safety.

Findings
The facility was found deficient in multiple areas including failure to provide required Medicare notices to residents, incomplete resident assessments, inaccurate Minimum Data Set (MDS) documentation, failure to follow physician orders for wound care, inadequate fall investigations and care planning, improper catheter care, incomplete medication orders lacking diagnosis or indication, failure to implement gradual dose reductions for psychotropic medications, inadequate staffing and staffing postings, medication storage and labeling issues, food safety violations, incomplete facility-wide assessment, failure to ensure vaccination offers and documentation, and malfunctioning call light systems.

Deficiencies (14)
Failed to provide Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN) for two residents discharged from Medicare Part A services.
Failed to complete quarterly assessments and significant change MDS for sampled residents.
Failed to ensure resident falls were accurately reflected on MDS and care plans were updated accordingly.
Failed to follow physician's orders for wound care on a surgical wound for one resident.
Failed to complete thorough fall investigation, document monitoring and neurological assessments, and update care plan for a resident with an unwitnessed fall.
Failed to ensure proper catheter care including sanitizing drainage port and hand hygiene; incomplete physician orders for catheter size.
Failed to post nurse staffing information in a location accessible to residents and visitors.
Failed to identify, assess, and provide supportive interventions for a resident with PTSD; care plan lacked triggers and interventions.
Failed to ensure all medication orders included a diagnosis or indication for use; failed to follow through on pharmacist recommendations for gradual dose reduction of psychotropic medications.
Failed to ensure medication storage and labeling met professional standards; medication carts left unlocked and unattended; expired medications present; controlled substances lock box unlocked.
Failed to keep dry storage room clean; food preparation items and equipment not sanitary; dumpsters not properly lidded; plastic cutting boards excessively scored risking cross-contamination.
Failed to complete a timely facility-wide assessment to determine resources necessary to meet resident needs including staff competencies, physical plant, and services.
Failed to ensure residents were offered influenza and pneumococcal vaccines, provide education on benefits and risks, obtain consent or document refusal, and document vaccination status for sampled residents.
Failed to ensure a complete, functioning call light system with audible notification throughout the facility to meet residents' needs timely.
Report Facts
Residents affected: 44 Medication treatment opportunities missed: 12 Medication treatment opportunities missed: 15 Fall risk score: 22 Residents on dementia unit: 16 Staff absence duration: 33 Expired medication count: 6

Employees mentioned
NameTitleContext
Social Services DirectorInterviewed regarding Medicare notices issuance
Regional NurseInterviewed regarding Medicare notices issuance and MDS completion
Director of NursingInterviewed regarding Medicare notices, MDS completion, wound care, medication orders, staffing, pharmacy recommendations, and call light system
Assistant Director of NursingInterviewed regarding MDS completion, wound care, medication orders, staffing, pharmacy recommendations, and infection preventionist duties
AdministratorInterviewed regarding MDS staffing, facility assessment, staffing postings, and call light system
Certified Nursing AssistantInterviewed regarding fall reporting and catheter care
Certified Medication TechnicianInterviewed regarding medication orders and catheter care
Licensed Practical NurseInterviewed regarding medication orders, medication cart security, and vaccination documentation
Dietary ManagerInterviewed regarding kitchen cleanliness and food safety
Director of MaintenanceInterviewed regarding call light system and dumpster lids
Corporate NurseInterviewed regarding infection preventionist duties

Inspection Report — Jul 16, 2024

Complaint Investigation
Date: Jul 16, 2024

Visit Reason
The inspection was conducted due to a complaint regarding the facility's failure to complete a thorough investigation of a resident's fall, document monitoring and neurological assessments after an unwitnessed fall, and update the resident's care plan with appropriate interventions.

Complaint Details
The investigation was complaint-related due to a resident (Resident #29) reporting an unwitnessed fall that was not properly investigated or documented by the facility. The resident reported the fall about a week after it occurred and was later sent to the hospital for a headache. The facility did not conduct a fall investigation or neurological checks as required.
Findings
The facility failed to properly investigate a resident's fall, did not document required neurological assessments or monitoring, and failed to update the care plan to prevent further falls. Interviews with staff and review of records confirmed these deficiencies.

Deficiencies (1)
Failed to complete a thorough investigation to determine the root cause of a resident's fall, document monitoring and neurological assessments after an unwitnessed fall, and update the resident's care plan with appropriate interventions.
Report Facts
Residents present: 44 Sampled residents: 12 Residents affected: 1

Employees mentioned
NameTitleContext
Certified Nurses Aide (CNA)Interviewed regarding notification and documentation of falls
Assistant Director of Nursing (ADON)Interviewed regarding fall investigation procedures and expectations
Director of Nursing (DON)Interviewed regarding expectations for fall investigations and documentation

Inspection Report — Apr 11, 2024

Annual Inspection
Date: Apr 11, 2024

Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory requirements related to resident care, treatment, and safety.

Findings
The facility failed to properly assess and document a resident's skin condition upon admission, ensure weekly skin assessments, notify physicians of skin issues, and correctly manage medication orders, resulting in actual harm to residents. Deficiencies were also found in wound care practices, catheter care, and the use of bed rails without proper assessment and consent.

Deficiencies (4)
Failed to completely assess and document one resident's skin upon admission and notify the physician of skin issues.
Failed to ensure weekly pressure ulcer assessments, proper hand hygiene during wound treatment, and correct application of wound products.
Failed to provide appropriate catheter care including hand hygiene and proper cleansing technique.
Failed to ensure side rails were used only when resident assessment indicated they were safe.
Report Facts
Residents affected: 4 Medication doses held: 2 Lasix dosage: 20 Potassium dosage: 10 Micafungin dosage: 50 Ampicillin/sulbactam dosage: 95

Employees mentioned
NameTitleContext
Licensed Practical Nurse ALicensed Practical NurseNamed in medication error finding and wound care observation
Certified Medication Technician ACertified Medication TechnicianNamed in medication administration error
Director of NursingDirector of NursingProvided information on wound care deficiencies and medication error
Assistant Director of NursingAssistant Director of NursingProvided information on wound care deficiencies and skin assessments
Certified Nursing Assistant ACertified Nursing AssistantNamed in catheter care deficiency and bed rail observation
Resident's PhysicianPhysicianProvided statements regarding notification failures and expectations

Inspection Report — Feb 21, 2023

Complaint Investigation
Date: Feb 21, 2023

Visit Reason
The inspection was conducted due to complaints regarding failure to obtain written authorization from the Power of Attorney for use of resident funds and failure to protect a resident from abuse by another resident.

Complaint Details
Complaint MO 00214015 related to unauthorized use of resident funds. Complaint MO 00213567 related to resident-to-resident abuse incident where Resident #39 hit Resident #43.
Findings
The facility failed to obtain proper authorization from the resident's Power of Attorney for financial transactions totaling $882.83. Additionally, the facility failed to prevent physical abuse when one resident hit another resident, and failed to identify root causes, implement ongoing behavior monitoring, or provide staff in-service after the incident.

Deficiencies (3)
Failed to obtain written authorization from the Power of Attorney for use of resident funds for one sampled resident.
Failed to ensure one resident was free from abuse when another resident hit him/her with a closed fist.
Failed to identify root cause for resident's physical aggression, document contributing factors, implement ongoing behavior monitoring, and provide staff in-service after resident-to-resident abuse incident.
Report Facts
Unauthorized funds spent: 882.83 Withdrawals: 4 BIMS score: 7 BIMS score: 4 Pain rating: 5 15 minute checks duration: 2

Employees mentioned
NameTitleContext
Licensed Practical Nurse BLPNProvided information on residents' behaviors and incident.
Certified Medication Technician ACMTProvided observations about residents' baseline behaviors and incident.
Certified Nursing Assistant BCNAWitnessed incident and provided details on residents' behaviors.
Social Service DirectorSocial Service DirectorProvided information on mental health follow-up and resident behaviors.
Director of NursingDONProvided information on incident, resident behaviors, and follow-up actions.
AdministratorAdministratorProvided information on incident investigation, mental health follow-up, and staff education.
Business Office ManagerBOMProvided information on unauthorized financial transactions and POA communication.
Activities DirectorActivities DirectorAdmitted to purchasing items for resident without POA authorization.
Corporate Director of OperationsCorporate Director of OperationsProvided information on facility's authority as representative payee.

Inspection Report — Dec 27, 2022

Routine
Date: Dec 27, 2022

Visit Reason
Routine inspection of Maywood Terrace Living Center to assess compliance with regulatory requirements including resident funds, Medicare notices, environmental conditions, resident rights, care planning, medication administration, wound care, fall prevention, smoking safety, and hospice services.

Findings
The facility had multiple deficiencies including failure to timely submit Third Party Liability forms after resident deaths, failure to serve Medicare Non-Coverage notices timely, inadequate temperature control on the North Unit during extreme cold, lack of physician orders and assessments for physical restraints, incomplete and non-person-centered care plans, failure to follow insulin administration timing, inadequate meaningful activities for dementia residents, failure to coordinate hospice care orders and plans, failure to monitor and document wounds comprehensively, failure to ensure fall prevention measures and safe smoking practices, failure to maintain medication and treatment carts locked, improper preparation of pureed food, failure to transcribe oxygen orders and maintain oxygen equipment properly, and failure to maintain safe environment including broken toilet tank and faucet handle.

Deficiencies (13)
Failed to submit Third Party Liability (TPL) form to Missouri HealthNet within 30 days of death of two residents.
Failed to serve Notice of Medicare Non-Coverage (NOMNC) timely to one resident.
Failed to maintain temperatures between 71°F and 81°F on North Unit during extreme cold weather, affecting 20 residents.
Failed to obtain physician orders and assessments for wheelchair seatbelt, gait belt, and half bedrail use for one resident.
Failed to develop comprehensive care plans addressing behavioral monitoring, meaningful activities, and medical/psychological needs for multiple residents.
Failed to follow physician orders and manufacturer instructions for insulin administration timing for one resident.
Failed to provide meaningful activities for residents on locked dementia unit.
Failed to accurately track and document wounds, failed to document weekly comprehensive skin assessments, and failed to obtain outside wound clinic notes for one resident with multiple wounds including Stage IV pressure ulcer.
Failed to ensure overlay bolster on low air loss mattress was monitored and fall prevention measures were in place for one resident at risk for falls; failed to complete and update Safe Smoking Evaluation for two residents; failed to ensure safe storage of smoking materials for one resident.
Failed to maintain proper hand hygiene during wound care and personal care, and failed to ensure proper catheter drainage bag placement for one resident at risk for infection.
Failed to ensure physician orders for oxygen were transcribed to resident's order sheet and oxygen supplies were properly stored and maintained for one resident.
Failed to ensure medication and treatment carts were kept locked to prevent tampering and ensure resident safety.
Failed to ensure food products were sealed, labeled, dated, and stored properly; failed to clean spills and discard spoiled food in kitchen.
Report Facts
Residents affected: 44 Residents affected: 20 Residents affected: 19

Employees mentioned
NameTitleContext
LPN BLicensed Practical NurseNamed in medication cart and wound care findings
CNA ECertified Nursing AssistantNamed in catheter care and oxygen supply findings
Maintenance Person BNamed in temperature and maintenance log findings
AdministratorNamed in multiple findings including wound care, hospice, and fall prevention
DONDirector of NursingNamed in multiple findings including wound care, hospice, and fall prevention
Cook ANamed in food preparation and thickening findings
Assistant Dietary ManagerNamed in food preparation and kitchen cleanliness findings
LPN ALicensed Practical NurseNamed in insulin administration and oxygen care findings
CNA KCertified Nursing AssistantNamed in fall incident
CNA DCertified Nursing AssistantNamed in catheter care findings
CNA FCertified Nursing AssistantNamed in smoking and catheter care findings
NA ANursing AssistantNamed in catheter care and nutritional assistance findings

Inspection Report — Oct 9, 2020

Life Safety
Date: Oct 9, 2020

Visit Reason
Federal Life Safety (CMS-2567) survey and Missouri state licensure (State Form); survey type: life safety.

Findings
Ten deficiencies were cited: five federal life safety K-tag deficiencies concerning storage of hazardous materials, means of egress, emergency lighting, smoke barrier doors, and fire drills; and five Missouri state deficiencies concerning exit requirements, emergency lighting, smoke section walls/doors, fire drill records, and substantial construction/maintenance.

Deficiencies (5)
K100 General Requirements - Other: The facility failed to store two five-gallon buckets of an unknown liquid in the boiler room properly; the buckets were uncovered and not labeled.
K211 Means of Egress - General: The facility failed to ensure the exit door at the end of West Hall opened easily; the door required extra force to open and had debris and rust preventing proper operation.
K291 Emergency Lighting: The facility failed to ensure emergency light fixtures illuminated when tested; emergency lights at the basement exit and the West Hall exit did not illuminate and wires/battery issues were identified.
K374 Subdivision of Building Spaces - Smoke Barrier Doors: The facility failed to ensure smoke barrier doors between specified areas closed properly during the fire alarm test, including gaps and improper meeting of leaves.
K712 Fire Drills: The facility failed to document the type of simulated fire in fire drill records; the fire drill documentation lacked the type of simulated fire for recorded drills.
Report Facts
buckets found: 2 residents potentially affected: 23 total smoke zones: 5

Inspection Report — Oct 9, 2020

Routine
Date: Oct 9, 2020

Visit Reason
The inspection was conducted to assess compliance with regulatory requirements including resident fund security, environmental cleanliness, resident care practices, medication management, dietary services, and infection control.

Findings
The facility was found deficient in maintaining a proper surety bond for resident funds, cleanliness of environmental surfaces including ceiling fans and medication carts, proper use of Hoyer lifts, follow-up on pharmacist recommendations for psychotropic medications, medication storage and labeling, food safety and preparation, dietary manager certification, and infection control practices including hand hygiene and appropriate use of gloves and personal protective equipment.

Deficiencies (10)
Failed to maintain a surety bond amounting to one and one half times the average monthly balance of resident trust funds, potentially affecting 32 residents.
Failed to ensure ceiling fans and vents were free of heavy dust buildup affecting residents in dining and bathing areas.
Failed to use Hoyer lift correctly by not locking wheelchair brakes during resident transfer, risking injury to residents.
Failed to ensure pharmacist recommendations for psychotropic medications were addressed and documented by the resident's physician.
Medication carts were not kept clean or free of expired medications and inappropriate items such as food and perfume were found in medication carts.
Failed to maintain pureed meatballs at or above 135°F on the steam table, risking food safety for residents on pureed diets.
Dietary Manager was not certified within one year of hire and no waiver was requested to allow more time for certification.
Failed to ensure pureed orzo pasta and bread recipes were followed for flavor due to lack of key ingredients.
Failed to maintain kitchen environment including dust on fans and light fixtures, debris in dishwasher nozzles, unlabeled sugar container, and unclean stainless steel table.
Failed to provide infection control by improper hand hygiene, glove use, and allowing staff identification badge to drag across resident's genital area during care.
Report Facts
Residents affected: 32 Surety bond amount: 15000 Required bond amount: 22000 Medication carts with issues: 2 Residents on pureed diet: 4 Residents on Hoyer lift: 11 Pharmacist recommendations not addressed: 6

Employees mentioned
NameTitleContext
CNA CCertified Nursing AssistantNamed in infection control deficiency related to glove use and badge dragging
LPN BLicensed Practical NurseNamed in infection control deficiency related to hand hygiene and medication administration
Dietary ManagerDietary ManagerNamed in deficiency related to lack of certification and food preparation
AdministratorInterviewed regarding surety bond, pharmacist recommendations, and dietary manager certification
Director of NursingDirector of NursingInterviewed regarding pharmacist recommendations and infection control
Assistant Director of NursingAssistant Director of NursingInterviewed regarding pharmacist recommendations and infection control
Certified Medication Technician ACertified Medication TechnicianNamed in medication cart cleanliness deficiency
Northside CoordinatorLicensed Practical NurseNamed in medication cart cleanliness deficiency
Maintenance DirectorMaintenance DirectorInterviewed regarding cleaning of fans and light fixtures
Dietary Aide ADietary AideObserved and interviewed regarding food preparation and kitchen cleanliness

Inspection Report — Apr 25, 2019

Life Safety
Date: Apr 25, 2019

Visit Reason
Federal CMS-2567 Life Safety (K tags) and Emergency Preparedness (E tags) forms and Missouri Department of Health and Senior Services State Form were included; the survey is a life safety survey.

Findings
27 deficiencies were cited: 10 federal Life Safety K-tag deficiencies addressing building construction/smoke penetration, exit discharge/egress obstructions, emergency lighting, protection (lint buildup), cooking range hood nozzles, fire alarm/testing, portable fire extinguishers, corridor doors, smoke barriers and fire drills; 5 federal Emergency Preparedness E-tag deficiencies addressing emergency planning for patient populations, collaboration/contact information, subsistence needs, waiver/roles, and backup communications; and 12 Missouri state licensure deficiencies largely reflecting the same fire-safety and operational policy failures.

Deficiencies (15)
K161 Building Construction Type and Height: Based on observation, interview and record review, the facility failed to ensure penetrations and holes behind walls and above ceilings were properly caulked or sealed in multiple areas (conference room, housekeeping closet, laundry area and social services), allowing the passage of smoke into interstitial areas.
K271 Discharge from Exits: The facility failed to maintain exit discharge areas and walkways free of obstructions and to maintain exit discharge surfaces, with electrical cords, debris, soil and mud observed obstructing exit discharges and walkways.
K291 Emergency Lighting: The facility failed to ensure emergency lighting illuminated as required when tested; emergency light bulbs in the West Hall medication room and at the front entrance did not illuminate during testing.
K300 Protection - Other: The facility failed to prevent heavy buildup of lint in dryer fireboxes and metal ducts and had combustible items stored near an electric hot water heater, creating unsafe conditions.
K324 Cooking Facilities: The facility failed to ensure the nozzles of the range hood extinguishing system were pointed directly at the six-burner stove and griddle.
K345 Fire Alarm System - Testing and Maintenance: The facility failed to ensure required semi-annual and annual fire alarm inspections/testing occurred within required intervals, with records showing inspections 196 days apart.
K355 Portable Fire Extinguishers: The facility failed to ensure the Class K fire extinguisher gauge was within the normal range and failed to place required signage stating the fire protection system shall be activated prior to using the fire extinguisher.
K363 Corridor - Doors: The facility failed to ensure corridor and room doors (including resident rooms and a soiled utility room) closed without obstruction; doors were observed obstructed or not self-closing.
K372 Subdivision of Building Spaces - Smoke Barrier: The facility failed to use fire-rated caulk to seal a penetration in a smoke barrier wall next to the Social Service office, compromising the smoke barrier.
K712 Fire Drills: The facility failed to ensure drill documentation showed receipt of alarm signals and failed to document at least one simulated fire drill in the kitchen or laundry areas annually.
E007 EP Program Patient Population: The facility failed to include in its disaster manual a plan for residents who depend on powered support devices (LALM, tube feeding pumps and oxygen concentrators).
E009 Local, State, Tribal Collaboration Process: The facility failed to place phone contact information for the Local Emergency Management Agency, State Emergency Management Agency, FEMA and the local branch of CMS in the disaster plan.
E015 Subsistence Needs for Staff and Patients: The facility failed to include the location of emergency water within the facility water outage plan and failed to include plans for portable commodes and staff implementation if the call-light system failed.
E026 Roles Under a Waiver Declared by Secretary: The facility failed to include a policy regarding procedures for carrying out an 1135 waiver, including the facility's role in providing care under waivers and how the facility would operate under a granted waiver.
E032 Primary/Alternate Means for Communication: The facility failed to include a backup communications system (to be used in the event of a landline or mobile phone outage) in the disaster manual.
Report Facts
residents potentially affected: 11 facility staff potentially affected: 7 residents potentially affected: 30 residents potentially affected: 35

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