Maryville Rehab: Improper Transfer Causes Actual Harm - MO
The violation was cited at F0689, the federal tag covering accidents and supervision, and was classified as causing actual harm to at least one resident.
The assistant director of nursing, known in inspection records as the ADON, told inspectors during an interview on October 8 that she had started training nursing staff on Monday, October 6, the same day pain or injury was discovered. That gap, between when the wrong transfer happened and when anyone began correcting it, was part of what inspectors documented.
The ADON described the retraining she launched. She said she was going through it with staff either in person or by phone, walking them through where to find a resident's transfer status in the electronic record, showing screenshots of the system, and explaining the difference between a mechanical lift transfer and a gait belt transfer. The core message she said she delivered was straightforward: nursing staff should not use a gait belt if the resident's care plan requires a mechanical lift.
That distinction matters. A mechanical lift is a piece of equipment designed to move a resident who cannot bear weight or who requires full support, reducing the physical strain on both the resident and the worker. A gait belt is a strap used to assist residents who can participate in their own transfer, providing a handhold for staff to guide and steady them. Using a gait belt on someone who needs a mechanical lift puts force on a body that cannot safely absorb it.
The ADON told inspectors that nursing staff are expected to know what each resident requires by checking the care plan, and that the transfer status is available in the electronic record. She said that if she witnessed an aide doing an improper transfer, she would stop them immediately and show them the correct method. She also said that if a resident fell or was lowered to the floor, staff should call for help, assess the resident, and contact emergency medical services if necessary.
What the inspection record shows is that at least one resident was not protected by that system before the harm occurred. The care plan existed. The electronic record contained the transfer status. The policy was in place. The injury happened anyway.
A separate staff member's account, also captured in the inspection record, described the same expectations. That staff member said he or she would look up the resident's information in the electronic record, would intervene if an improper transfer was observed, and would call for help and assess the resident if someone fell.
The retraining the ADON described after the fact covered the transfer policy, mechanical lift procedures, gait belt procedures, and how to locate the relevant information in the electronic record. It was not proactive instruction. It was a response to a resident already hurt.
The inspection was triggered by a complaint, file number Intake 2636283, and concluded in November 2025. The actual harm finding means federal reviewers determined the violation caused more than minimal discomfort, rising to the level of real injury or deterioration.
Maryville Rehabilitation & Health Care Center is a licensed facility in Maryville, Missouri.
The resident who was transferred the wrong way is identified in inspection records only by number. Whether they recovered fully is not stated in the report.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Maryville Rehabilitation & Health Care Center from 2025-11-17 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 1, 2026 · Our methodology
MARYVILLE REHABILITATION & HEALTH CARE CENTER in MARYVILLE, MO was cited for violations during a health inspection on November 17, 2025.
The violation was cited at F0689, the federal tag covering accidents and supervision, and was classified as causing actual harm to at least one resident.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.