Maryville Living Center: Improper Discharge Violation - MO
That was the entirety of the official record Maryville Living Center produced when it decided a severely cognitively impaired resident would not be coming back.
The resident, identified only as Resident #1 in inspection records, had been living at the 46-bed facility after suffering a stroke. His or her medical record documented brain damage, amnesia, vision loss, and a score of three on a standard cognitive assessment, a number that indicates significant cognitive loss. The resident had hallucinations. The resident had behaviors.
Those behaviors were serious. A care plan from March 30 documented that the resident had wrapped a call light cord around his or her own neck, though denied any intent to self-harm. The resident had shoulder-bumped another resident, kicked a neighboring resident's television, torn wooden trim from a wall, and stood on an air conditioning unit. Staff had placed the resident on 15-minute checks as of May 18.
Then came the night of May 13.
Nurse progress notes recorded what unfolded over roughly 12 hours. At 11:43 in the morning, the resident had returned from a hospital visit with no behaviors and a new prescription for hydroxyzine, an anti-anxiety medication, to be given by injection every six hours as needed. By 8:31 that evening, the resident was asking staff to kill him or her, describing in detail how it should be done. The resident took the handle off a broom and asked staff to hit him or her with it. When staff tried to redirect, the resident grew more agitated. A light fixture was pulled from the wall. Window screens were ripped out. The resident attempted to punch through the windows. Staff moved to one-on-one observation. Just before midnight, emergency medical services and law enforcement arrived, and the resident was transported to the emergency room.
A week later, on May 20, the resident was admitted to the hospital again for what notes described as increased violent behaviors.
That second hospitalization was the last time the resident would be considered a patient at Maryville Living Center. The administrator told inspectors on May 27 that an emergency discharge had been initiated when the resident went to the hospital, because he or she was a danger to other residents. The Director of Nursing had completed the transfer and discharge paperwork.
The form that resulted was nearly empty.
Federal rules require discharge notices to include the resident's name, the facility's name, contact information, the name of the resident's representative, the date of transfer, and the location where the resident is being sent. None of that appeared on the form Maryville Living Center filed. The facility also had no discharge policy at all, something the administrator confirmed directly to inspectors: "There was not a transfer and discharge policy."
The administrator said he or she would have expected the paperwork to be complete when a resident was discharged. It was not.
The inspection, conducted May 27 as a complaint investigation, cited the facility for failing to provide an appropriate discharge. Inspectors noted that the facility's own undated notice form listed one permissible reason for transfer: that the safety of individuals in the facility is endangered. The facility checked that box. It filled in nothing else.
What happened to the resident after the second hospitalization, where he or she was sent, and who, if anyone, was coordinating that transition, does not appear in the inspection record.
A person with brain damage, amnesia, and a cognitive score of three, someone whose behaviors were documented as the product of neurological injury rather than intent, was discharged from a nursing facility into an unknown destination, on an unknown date, with a form that named nobody and went nowhere.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Maryville Living Center from 2026-05-27 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 12, 2026 · Our methodology
MARYVILLE LIVING CENTER in MARYVILLE, MO was cited for violations during a health inspection on May 27, 2026.
The resident, identified only as Resident #1 in inspection records, had been living at the 46-bed facility after suffering a stroke.
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.