Avalon View Health: Scabies Spread After Staff Left Unwarned - MO
That finding sits at the center of a complaint inspection completed November 20, 2025, at the Liberty facility. Inspectors documented that staff were providing hands-on care to residents diagnosed with scabies without contact precautions in place, and that multiple caregivers said they had never been told any resident in the building had the condition.
Scabies is caused by microscopic mites that burrow into skin and spread through direct physical contact. In a nursing home, where staff move between residents throughout a shift and residents share common spaces, an uncontrolled outbreak can move quickly.
The dermatologist's physician assistant who had examined the residents told inspectors that all three, identified in the report as Residents 1, 2, and 3, had active infections at the time of their dermatology appointments. The PA said he or she would expect the facility to place those residents on contact precautions immediately after diagnosis, and that facilities typically have a protocol covering exactly this situation, including isolation measures. None of that, inspectors found, had happened.
A certified medication technician identified in the report as CMT B told inspectors he or she was "unaware of any residents being diagnosed with scabies." CMT C said the same thing, adding that he or she would have worn a gown, gloves, and a mask when caring for an infected resident, specifically because some residents like to touch his or her face. A registered nurse, identified as RN A, said a scabies diagnosis would trigger contact precautions. But precautions only work if the people providing care know they are needed.
One aide described the gap plainly. If he or she had known the resident had scabies, the aide told inspectors, he or she would have had gloves and a gown on and followed contact precautions. The implication was direct: the aide had not known, had not been told, and had gone in without protection.
The inspection covered six separate complaint intakes, a volume that suggests the concerns reaching regulators were not isolated.
What the report does not explain is how long the gap lasted. The inspection does not specify when Residents 1, 2, and 3 were diagnosed, when their dermatology appointments occurred, or how many shifts passed between those diagnoses and the moment inspectors arrived and began asking questions. The staff interviews took place on November 19. The dermatologist's PA spoke with inspectors the following morning. By that point, multiple caregivers across different roles, an aide, two medication technicians, and a registered nurse, all described the same thing: they had not heard that anyone in the building had scabies.
The violation was cited at a level of minimal harm or potential for actual harm, affecting some residents. That language reflects the regulatory classification, not necessarily the scope of exposure. Staff who provided unprotected care to residents with active infections were themselves at risk of contracting scabies and carrying it to other residents, family members, or their own households. The report does not document whether any additional residents or staff developed symptoms.
What it does document is a breakdown in the most basic layer of infection control: telling the people delivering care what they are walking into.
The dermatologist's PA put it without qualification. He or she would expect the facility to follow its infection control guidelines to prevent the spread of scabies. The staff who spoke with inspectors described, in their own words, exactly what they would have done differently if anyone had told them.
Nobody had.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Avalon View Health and Wellness from 2025-11-20 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: August 27, 2026 · Our methodology
AVALON VIEW HEALTH AND WELLNESS in LIBERTY, MO was cited for violations during a health inspection on November 20, 2025.
That finding sits at the center of a complaint inspection completed November 20, 2025, at the Liberty facility.
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.