Life Care Center of Waynesville: Care Standard Gaps - MO
The November 5 incident at Life Care Center of Waynesville involved Resident #5, who staff assessed as severely cognitively impaired with Parkinson's disease. The resident received ezetimibe for high cholesterol, simvastatin for heart attack prevention, Vistaril for anxiety, and trazodone for depression — none of which appeared on his physician's order sheet.
Progress notes from 12:25 a.m. that night documented the severity of the error: "Resident took ezetimibe, simvastatin, Vistaril, or trazodone. Resident attempted to ambulate to restroom, he/she is quite sedated from trazodone. Resident was educated on fall risk and agreed to call for assistance with transfers."
Staff tried to reach the resident's family but found the phone line disconnected. They notified the physician, who directed continuous monitoring throughout the night.
The medication technician, identified as CMT C in facility records, explained the mix-up in a November 4 statement: "I gave a med cup to the wrong resident. I had gotten done passing meds on my hall and went to go help. The nurse had popped the meds into a med cup and handed it to me. There was a miscommunication, and I gave the meds to the wrong resident in the room."
During federal inspectors' November 24 visit, the resident described his experience: "I was so tired and had a lot of weird dreams after the error." He said he didn't know what medication he received or how the mistake happened, but staff checked on him repeatedly during the night.
The error occurred during a staffing shortage. CMT B, interviewed December 9, said the facility was short a nurse and an agency nurse arrived late to help. After finishing his own medication rounds, he went to assist the overwhelmed nurse.
"The nurse gave me a pill cup to take to a resident," CMT B explained to inspectors. "I was unfamiliar with the residents on that hall and there were two residents in the room and I gave the medication to the wrong resident."
He immediately told the nurse about the error, who then called department heads and the physician. CMT B said he hasn't seen that agency nurse since the incident.
The Director of Nursing confirmed during the November 24 interview that Resident #5 received his roommate's medications. She said the physician was notified and the resident experienced tiredness but no other side effects.
Federal inspectors found the facility violated medication safety standards by failing to follow the "10 rights of medication administration," particularly the requirement to use two patient identifiers and verify the resident's identity before giving drugs.
The facility's own medication policy, reviewed September 9, requires staff to "ensure medications are administered safely and appropriately per physician order." The policy specifically states that medication administration must be performed by certified and licensed individuals authorized in Missouri to dispense drugs in skilled nursing facilities.
CMT B acknowledged to inspectors that he violated fundamental safety protocols: "I am aware I should never pass medications that I did not prepare but I tried to help to get the residents their medications on time."
The Director of Nursing provided additional education to CMT B on proper medication administration following the incident.
Life Care Center of Waynesville houses 76 residents. Federal inspectors classified this as a medication error causing minimal harm or potential for actual harm, though the resident's severe sedation and mobility impairment created clear fall risks for someone already diagnosed with Parkinson's disease.
The resident spent the night heavily sedated from trazodone, a depression medication he wasn't prescribed, while staff monitored him for adverse reactions. His family remained unreachable due to a disconnected phone line, leaving him without outside support during the incident.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Life Care Center of Waynesville from 2025-11-24 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 21, 2026 · Our methodology
LIFE CARE CENTER OF WAYNESVILLE in WAYNESVILLE, MO was cited for violations during a health inspection on November 24, 2025.
The November 5 incident at Life Care Center of Waynesville involved Resident #5, who staff assessed as severely cognitively impaired with Parkinson's disease.
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.