Inspection Report Summary
The most recent inspection on March 19, 2025, found deficiencies related to the facility’s failure to properly account for the delivery and storage of controlled substances, including issues with narcotic count reconciliations and staff education. Earlier inspections showed a pattern of deficiencies in medication management, resident care documentation, wound and catheter care, fall investigations, and environmental safety. Complaint investigations included substantiated findings of improper medication handling and incomplete fall investigations, as well as issues with resident funds and abuse prevention. Enforcement actions such as fines or license suspensions were not listed in the available reports. The facility’s inspection history indicates ongoing challenges with medication and care processes, with no clear improvement trend evident.
Deficiencies (last 5 years)
Deficiencies (over 5 years)
9.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
78% worse than Missouri average
Missouri average: 5.5 deficiencies/yearDeficiencies per year
16
12
8
4
0
Census
Latest occupancy rate
41 residents
Based on a March 2025 inspection.
Occupancy over time
Inspection Report
Complaint Investigation
Census: 41
Deficiencies: 4
Date: Mar 19, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to properly account for the delivery and storage of controlled substances, specifically 120 tablets of Oxycodone 20 mg for one resident.
Complaint Details
The complaint investigation found that the facility failed to properly account for controlled substance delivery and storage. The DON was notified that the resident had only one tablet left and was unsure if the pharmacy had delivered more. Investigation revealed discrepancies in medication counts and documentation. RN A admitted to signing delivery slips without verifying counts. The facility lacked proper narcotic count reconciliation with two licensed staff signatures on multiple shifts. The DON expected narcotic counts each shift with two staff signatures and proper medication storage. RN A did not respond to contact attempts post-investigation.
Findings
The facility failed to properly account for the delivery of 120 tablets of Oxycodone 20 mg for Resident #1. The Director of Nursing (DON) found discrepancies in narcotic counts, incomplete narcotic count reconciliations without two licensed staff signatures on multiple shifts, and improper medication receipt procedures. RN A signed for medication without verifying the count, and no education had been provided to staff since the incident.
Deficiencies (4)
Failed to properly account for delivery of 120 tablets of Oxycodone 20 mg for one resident.
Narcotic counts were not verified by two licensed staff signatures on multiple shifts between 3/7/25 and 3/18/25.
RN A signed delivery receipt without confirming correct medication and count was received.
No education provided to staff on controlled substance storage since the incident.
Report Facts
Medication tablets: 120
Facility census: 41
Dates missing two licensed staff signatures: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN A | Registered Nurse | Signed for medication delivery without verifying count; involved in narcotic count discrepancies |
| LPN A | Licensed Practical Nurse | On-coming nurse who reported RN A did not do full narcotic count |
| LPN B | Licensed Practical Nurse | Described proper medication receipt and narcotic count procedures during interview |
| Director of Nursing | Director of Nursing (DON) | Conducted investigation, reviewed records, and provided statements on expectations and findings |
Inspection Report
Routine
Census: 44
Capacity: 86
Deficiencies: 14
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
Total capacity: 86
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
| Name | Title | Context |
|---|---|---|
| Social Services Director | Interviewed regarding Medicare notices issuance | |
| Regional Nurse | Interviewed regarding Medicare notices issuance and MDS completion | |
| Director of Nursing | Interviewed regarding Medicare notices, MDS completion, wound care, medication orders, staffing, pharmacy recommendations, and call light system | |
| Assistant Director of Nursing | Interviewed regarding MDS completion, wound care, medication orders, staffing, pharmacy recommendations, and infection preventionist duties | |
| Administrator | Interviewed regarding MDS staffing, facility assessment, staffing postings, and call light system | |
| Certified Nursing Assistant | Interviewed regarding fall reporting and catheter care | |
| Certified Medication Technician | Interviewed regarding medication orders and catheter care | |
| Licensed Practical Nurse | Interviewed regarding medication orders, medication cart security, and vaccination documentation | |
| Dietary Manager | Interviewed regarding kitchen cleanliness and food safety | |
| Director of Maintenance | Interviewed regarding call light system and dumpster lids | |
| Corporate Nurse | Interviewed regarding infection preventionist duties |
Inspection Report
Complaint Investigation
Census: 44
Deficiencies: 1
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
| Name | Title | Context |
|---|---|---|
| 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
Annual Inspection
Census: 49
Deficiencies: 4
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
Facility census: 49
Medication doses held: 2
Lasix dosage: 20
Potassium dosage: 10
Micafungin dosage: 50
Ampicillin/sulbactam dosage: 95
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse A | Licensed Practical Nurse | Named in medication error finding and wound care observation |
| Certified Medication Technician A | Certified Medication Technician | Named in medication administration error |
| Director of Nursing | Director of Nursing | Provided information on wound care deficiencies and medication error |
| Assistant Director of Nursing | Assistant Director of Nursing | Provided information on wound care deficiencies and skin assessments |
| Certified Nursing Assistant A | Certified Nursing Assistant | Named in catheter care deficiency and bed rail observation |
| Resident's Physician | Physician | Provided statements regarding notification failures and expectations |
Inspection Report
Complaint Investigation
Census: 46
Deficiencies: 3
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
Resident census: 46
Withdrawals: 4
BIMS score: 7
BIMS score: 4
Pain rating: 5
15 minute checks duration: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse B | LPN | Provided information on residents' behaviors and incident. |
| Certified Medication Technician A | CMT | Provided observations about residents' baseline behaviors and incident. |
| Certified Nursing Assistant B | CNA | Witnessed incident and provided details on residents' behaviors. |
| Social Service Director | Social Service Director | Provided information on mental health follow-up and resident behaviors. |
| Director of Nursing | DON | Provided information on incident, resident behaviors, and follow-up actions. |
| Administrator | Administrator | Provided information on incident investigation, mental health follow-up, and staff education. |
| Business Office Manager | BOM | Provided information on unauthorized financial transactions and POA communication. |
| Activities Director | Activities Director | Admitted to purchasing items for resident without POA authorization. |
| Corporate Director of Operations | Corporate Director of Operations | Provided information on facility's authority as representative payee. |
Inspection Report
Routine
Census: 44
Deficiencies: 13
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
| Name | Title | Context |
|---|---|---|
| LPN B | Licensed Practical Nurse | Named in medication cart and wound care findings |
| CNA E | Certified Nursing Assistant | Named in catheter care and oxygen supply findings |
| Maintenance Person B | Named in temperature and maintenance log findings | |
| Administrator | Named in multiple findings including wound care, hospice, and fall prevention | |
| DON | Director of Nursing | Named in multiple findings including wound care, hospice, and fall prevention |
| Cook A | Named in food preparation and thickening findings | |
| Assistant Dietary Manager | Named in food preparation and kitchen cleanliness findings | |
| LPN A | Licensed Practical Nurse | Named in insulin administration and oxygen care findings |
| CNA K | Certified Nursing Assistant | Named in fall incident |
| CNA D | Certified Nursing Assistant | Named in catheter care findings |
| CNA F | Certified Nursing Assistant | Named in smoking and catheter care findings |
| NA A | Nursing Assistant | Named in catheter care and nutritional assistance findings |
Inspection Report
Routine
Census: 40
Deficiencies: 10
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
Facility census: 40
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
| Name | Title | Context |
|---|---|---|
| CNA C | Certified Nursing Assistant | Named in infection control deficiency related to glove use and badge dragging |
| LPN B | Licensed Practical Nurse | Named in infection control deficiency related to hand hygiene and medication administration |
| Dietary Manager | Dietary Manager | Named in deficiency related to lack of certification and food preparation |
| Administrator | Interviewed regarding surety bond, pharmacist recommendations, and dietary manager certification | |
| Director of Nursing | Director of Nursing | Interviewed regarding pharmacist recommendations and infection control |
| Assistant Director of Nursing | Assistant Director of Nursing | Interviewed regarding pharmacist recommendations and infection control |
| Certified Medication Technician A | Certified Medication Technician | Named in medication cart cleanliness deficiency |
| Northside Coordinator | Licensed Practical Nurse | Named in medication cart cleanliness deficiency |
| Maintenance Director | Maintenance Director | Interviewed regarding cleaning of fans and light fixtures |
| Dietary Aide A | Dietary Aide | Observed and interviewed regarding food preparation and kitchen cleanliness |
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