Citations in Missouri
Comprehensive analysis of citations, statistics, and compliance trends for long-term care facilities in Missouri.
Statistics for Missouri (Last 12 Months)
Financial Impact (Last 12 Months)
Latest Citations in Missouri
A resident with multiple medical conditions and moderate cognitive impairment was forced out of bed by a CMT despite expressing a desire to remain in bed due to pain. The CMT disregarded the resident's refusal, used excessive force, and failed to notify the charge nurse as required. The incident was witnessed by an OTA and left the resident feeling uneasy and diminished.
A physical altercation occurred between two residents with severe cognitive impairment, resulting in both falling to the floor. Although staff separated the residents, assessed them for injuries, and notified their families and physicians, the required report to DHSS was not made within the mandated two-hour timeframe. Interviews revealed confusion among staff and leadership regarding reporting requirements, leading to a deficiency in timely reporting of suspected abuse.
Staff did not consistently separate residents who tested positive for COVID-19 from those who tested negative, resulting in both groups sharing rooms and common areas without masks. Several residents were not consulted about room changes despite their preferences, and staff interviews revealed confusion about which residents were COVID-positive and a lack of proper signage and PPE disposal. Leadership acknowledged that while a list of positive residents was available, not all staff were aware of it or following infection control protocols.
A resident with a history of aggressive behaviors was sent to a hospital for psychiatric evaluation after multiple assaults on staff. The facility issued an immediate discharge notice while the resident was hospitalized, but failed to specify an appropriate discharge location as required, instead listing the psychiatric hospital. The discharge notice was not amended to correct this, resulting in a deficiency.
A staff member gave an after-visit summary containing PHI for a resident to the family of another resident, including details such as name, date of birth, and medical information. When notified of the error, the staff member showed indifference and did not retrieve the document, resulting in a breach of confidentiality.
Surveyors found that the facility did not maintain a homelike environment, as evidenced by unswept rooms, protruding screws on furniture, and dirty plates left in resident rooms for days. Additionally, due to a shortage of regular dining plates, residents were frequently served meals on Styrofoam plates, which led to dissatisfaction and complaints about food quality and temperature. Staff and supervisors acknowledged these issues and cited staffing shortages and supply problems as contributing factors.
A resident with opioid dependence and other medical conditions received Oxycodone for pain management. The facility lost one narcotic count sheet for a card of 30 Oxycodone tablets, resulting in no reconciliation for those doses. While the MAR showed administration of the medication, the required controlled substance documentation was incomplete, and staff interviews confirmed the missing record.
A facility failed to report an alleged incident of sexual abuse between two residents to law enforcement and the state survey agency within the required timeframe, despite its own policy and federal regulations. The incident involved a resident with severe cognitive impairment and another resident with a history of inappropriate sexual behavior. Staff and family were aware of the allegation, but administration decided not to report it after reviewing camera footage and assessments, and the hospice agency was not notified by the facility.
A facility failed to follow its abuse prevention policy by not conducting a documented investigation or notifying authorities after an allegation that a resident with severe cognitive impairment was sexually abused by another resident with a history of inappropriate sexual behavior. Despite staff and family reports of the incident and the facility's own policy requirements, the Administrator determined the allegation was unsubstantiated without a formal investigation or external reporting.
Three residents with significant care needs did not receive scheduled bi-weekly showers over several months, with missed showers not consistently documented and some residents reporting no alternative hygiene care. Interviews and observations confirmed lapses in shower provision, documentation, and staff encouragement, resulting in residents experiencing poor hygiene and unaddressed personal care needs.
Resident's Right to Dignity Violated by Forced Transfer from Bed
Penalty
Summary
A Certified Medication Technician (CMT) failed to honor a resident's right to self-determination and dignity by forcing the resident out of bed against their will. The resident, who had diagnoses including COPD, spondylosis, anemia, hyperlipidemia, and left-sided hemiplegia, was moderately cognitively impaired and reported increased leg pain on the day of the incident. Despite the resident's clear verbal refusal to get out of bed and participate in therapy, the CMT insisted, placed pants on the resident while they resisted, and physically moved the resident from a supine position to a wheelchair. An Occupational Therapist Assistant (OTA) witnessed the event and confirmed that the resident expressed a desire not to participate in therapy due to pain. The OTA observed the CMT using excessive force and commented on the roughness of the interaction. The resident later reported feeling uneasy and diminished by the experience, stating that the CMT spoke loudly and disregarded their wishes, which made them feel small and uncomfortable. During interviews, the CMT acknowledged being familiar with the facility's resident rights policy but admitted to not notifying the charge nurse when the resident refused to get out of bed. The CMT stated that they were concerned about medication administration and the resident's position but did not follow proper protocol for handling refusals. The Social Services Designee and the facility Administrator both confirmed that the resident's rights were not honored, and the incident was documented as a violation of the resident's right to dignity and choice.
Failure to Timely Report Resident-to-Resident Physical Altercation
Penalty
Summary
The facility failed to report an allegation of possible physical abuse between two residents to the State Survey Agency (SSA) within the required two-hour timeframe. The incident involved one resident throwing a spoon at another during lunch, followed by a physical altercation in which one resident pushed the other, resulting in both residents falling to the floor. The event was witnessed by a family member and staff, and both residents were assessed for injuries, with none observed. However, there was no documentation that the incident was reported to the Department of Health and Senior Services (DHSS) as required by facility policy and state regulations. Both residents involved had severe cognitive impairment and diagnoses including Alzheimer's disease, with one resident also having sick sinus syndrome. Their care plans did not address any prior history of resident-to-resident altercations. Staff responded to the incident by separating the residents, assessing them for injuries, and notifying their families and physicians. Despite these actions, the required notification to DHSS was not completed or documented. Interviews with staff, including CNAs, a CMT, an LPN, the DON, and the Administrator, revealed inconsistent understanding of the reporting requirements. Some staff believed that reporting to DHSS was required within 24 hours, while others stated it should be done within two hours. The DON and Administrator both acknowledged that the incident should have been reported to DHSS, but neither completed the report, with the Administrator stating he believed it was not necessary if both residents were confused and there was no harm. This failure to report the incident constituted a deficiency in timely reporting of suspected abuse as required by policy and regulation.
Failure to Cohort and Isolate COVID-19 Positive Residents
Penalty
Summary
Facility staff failed to maintain an effective infection prevention and control program, specifically in the management of residents who tested positive for COVID-19. Despite having a policy that directs staff to isolate or cohort residents with confirmed or suspected SARS-CoV-2 infection, staff did not consistently separate residents who tested positive from those who tested negative. Multiple observations showed that residents with positive COVID-19 test results were housed in the same rooms as residents with negative results, and neither group consistently wore masks. Additionally, COVID-positive residents were observed in common areas, such as hallways and dining rooms, in close proximity to other residents and staff. Interviews with residents and their representatives revealed that several residents were not asked if they wanted to move rooms when their roommate tested positive for COVID-19, despite expressing a preference not to share a room with an infected individual. Staff interviews indicated a lack of clear communication and awareness regarding which residents were COVID-positive. Some staff members, including a Certified Medication Technician and the Assistant Director of Nursing, were unaware of the COVID status of residents or the absence of appropriate signage and PPE disposal materials in affected rooms. The Infection Preventionist acknowledged that interventions such as room trays, some room changes, and mask usage had been implemented, but also noted that many residents refused to wear masks outside their rooms. Leadership interviews highlighted inconsistencies in staff education and communication regarding infection control protocols. While a list of COVID-positive residents was reportedly posted at the nurse's station, several staff members were unaware of it or did not know which residents required isolation or specific PPE. The Director of Nursing and Infection Preventionist were identified as responsible for ensuring compliance, but gaps in implementation and staff knowledge were evident throughout the facility.
Failure to Properly Identify Discharge Location During Immediate Discharge
Penalty
Summary
The facility failed to follow proper immediate discharge procedures for a resident who exhibited increased aggressive behaviors, including multiple physical assaults on staff. After a series of incidents involving physical aggression, law enforcement intervention, and psychiatric evaluation, the resident was sent to a hospital. The facility then determined it could not meet the resident's needs and issued an immediate discharge notice while the resident was at the hospital. However, the discharge notice identified the psychiatric hospital as the discharge location, which did not meet regulatory requirements for specifying an appropriate discharge location. The facility's policy required that, in cases of emergency transfer and subsequent discharge, the discharge location must be properly identified and the resident's status must be evaluated based on their condition at the time of transfer. Despite this, the facility did not amend the immediate discharge notice to reflect an appropriate discharge location after being informed of the error. The discharge letter was also improperly dated, and there was no documentation explaining why the resident was taken into custody on one of the dates in question. The resident, who had a guardian, remained in the hospital pending a hearing after the discharge was appealed. The facility had attempted to find an alternative placement for the resident for several months but was unsuccessful due to the resident's aggressive behaviors. The failure to properly identify a discharge location and to amend the discharge notice as required constituted the deficiency cited in the report.
Failure to Protect Resident Health Information Confidentiality
Penalty
Summary
The facility failed to maintain the confidentiality of protected health information (PHI) when a staff member provided an after-visit summary containing personal and medical details of one resident to the family member of a different resident. The summary included the resident's full name, date of birth, medical record number, referrals for further testing, and results of a recent x-ray. The family member who received the document reported the error to the staff member, but the staff member responded indifferently, stating they did not care and did not want the paperwork back, allowing the family member to keep the document. The incident was confirmed through interviews, observation, and record review. The family member retained the after-visit summary and provided it to the surveyor as evidence. The facility's posted resident rights statement included confidentiality, and management acknowledged that only residents, their guardians, or POAs should have access to such records. The administrator stated that, in such cases, staff are expected to retrieve the documents and notify management, but this did not occur in this instance.
Failure to Maintain Homelike Environment and Adequate Dining Service
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment for its residents, as evidenced by multiple observations and interviews. One resident with moderate cognitive impairment, a history of stroke, aphasia, hemiplegia, and schizophrenia was found in a room that was not swept daily, with trash on the floor and a bedside table with screws protruding from the surface. The condition persisted over two days, and the housekeeping supervisor acknowledged that the screws were not homelike and that the table was an older, unused piece of furniture. Housekeeping staff were expected to clean rooms daily, but staffing shortages were noted. Another resident, who was cognitively intact and had diagnoses including diabetes, hypertension, and hemiplegia, had two dirty plates with dried food left on the air conditioning unit in their room for at least two days. The resident reported that the plates were from previous meals, and the housekeeping supervisor stated that staff should remove such items or notify nursing. The supervisor also noted that trash should be removed in the morning and rooms checked again before staff leave, but acknowledged recent short staffing. Additionally, the facility did not provide a sufficient number of regular dining plates, resulting in residents being served meals on Styrofoam plates wrapped in plastic. Multiple residents reported dissatisfaction with the use of Styrofoam, stating that it made food cold and unappetizing, and that plates were often removed before they finished eating so they could be washed for the next meal. Observations confirmed that regular plates were in short supply, with staff switching to Styrofoam when plates ran out. The dietary manager and staff confirmed the ongoing shortage, and the administrator provided documentation of a recent order for a small number of plates, but could not locate records of previous orders.
Failure to Maintain Accurate Controlled Substance Records
Penalty
Summary
The facility failed to maintain a complete and accurate record of receipt and disposition of all controlled drugs for a resident, resulting in the loss of a narcotic count sheet for one card of 30 Oxycodone 20 mg tablets. The pharmacy delivered a 30-day supply of 120 tablets, divided into four cards of 30 tablets each, and records confirmed receipt by the facility. While three of the four controlled substance sheets were available and reconciled, one sheet was missing, leaving no documentation or reconciliation for the administration of 30 tablets. The medication administration record (MAR) showed that doses were given and documented, but the corresponding narcotic count sheet for one card could not be located. Interviews with staff revealed that narcotic medications are signed in upon delivery and are supposed to be accounted for on controlled substance sheets, with reconciliation at the beginning and end of each shift. The LPN interviewed did not recall any discrepancies or resident complaints regarding pain medication. The DON confirmed the missing narcotic sheet and stated that all sheets should be accounted for, with staff expected to sign out and document administration of controlled medications. The administrator also acknowledged the expectation for accurate reconciliation of narcotics.
Failure to Timely Report Alleged Sexual Abuse to Authorities
Penalty
Summary
The facility failed to follow its own abuse prevention policy and federal and state regulations by not reporting an alleged incident of sexual abuse involving a resident to law enforcement and the state survey agency within the required two-hour timeframe. The policy clearly mandates immediate reporting of suspected abuse, including sexual abuse, to the appropriate authorities, but this was not done in this case. The incident involved one resident allegedly attempting to put their hands down another resident's pants in a common area, as witnessed by staff and other residents. The resident who was the alleged victim had significant cognitive impairment, including diagnoses of senile degeneration of the brain, dementia with agitation, and major depressive disorder. The resident required assistance with activities of daily living and exhibited behaviors such as yelling and agitation. The alleged perpetrator also had cognitive deficits and a history of making inappropriate sexual comments, and was placed on one-to-one supervision following the incident. Despite these factors and the facility's policy, the incident was not reported to the state survey agency, law enforcement, or the hospice agency caring for the resident. Interviews revealed that staff were aware of the incident and that the family of the alleged victim was notified. However, the facility's administration determined, after reviewing camera footage and conducting assessments, that the incident did not occur as initially reported and therefore did not report it to authorities. The hospice agency only became aware of the incident after being informed by the resident's family, not by the facility. The failure to report the allegation as required constitutes the deficiency.
Failure to Investigate and Report Alleged Sexual Abuse
Penalty
Summary
The facility failed to follow its abuse prevention policy and did not ensure that an alleged incident of sexual abuse involving a resident was properly investigated. According to the facility's policy, all allegations of abuse, including sexual abuse, must be promptly and thoroughly investigated, with appropriate notifications made to authorities and documentation of all investigative steps. However, when an allegation was made that one resident put their hands down another resident's pants in a common area, the facility did not conduct a documented investigation as required by policy. The Administrator relied on a review of camera footage, which was later stated to be unavailable, and determined the allegation was unsubstantiated without further inquiry or reporting to the state survey agency or law enforcement. The resident involved in the alleged incident had significant cognitive impairment, as evidenced by a BIMS score of zero and diagnoses including dementia with agitation, senile degeneration of the brain, and major depressive disorder. The resident was also receiving hospice services and required assistance with activities of daily living. The alleged perpetrator had a history of making inappropriate sexual comments and was placed on one-to-one supervision following the incident. Despite these factors and the facility's policy requiring investigation and reporting, the Administrator did not initiate a formal investigation or notify external authorities. Interviews with staff and the resident's family revealed inconsistencies in the facility's response. The family was informed by nursing staff that the incident had been witnessed by others and that an assessment found no injuries or signs of distress. However, the Administrator later stated there was no camera footage and that the incident did not warrant reporting or further investigation. The lack of a documented investigation and failure to follow established protocols resulted in a deficiency related to the facility's handling of abuse allegations.
Failure to Provide Scheduled Showers and Document Refusals
Penalty
Summary
The facility failed to provide showers as scheduled for three residents out of six sampled, despite having a policy requiring bi-weekly showers and documentation of refusals or missed showers. Review of shower sheets and schedules revealed that these residents missed multiple scheduled showers over a three-month period, with some months showing no showers provided at all for certain residents. The facility's policy also required that refusals be documented and reported, but there was evidence that this was not consistently done. Resident #1, who had diagnoses including multiple sclerosis and COPD and was dependent on staff for showering, missed the majority of scheduled showers from October to December. Resident #2, with COPD, heart failure, and rheumatoid arthritis, also missed nearly all scheduled showers during the same period and reported not receiving bed baths in between. Resident #5, who required substantial assistance due to muscle weakness and Parkinson's disease, similarly missed several scheduled showers, with some refusals documented but others not clearly accounted for. Interviews with residents and staff confirmed the lack of regular showers, with residents expressing a desire for more frequent bathing and staff acknowledging ongoing issues with shower provision and documentation. Observations included musty odors and unkempt appearance, and staff interviews indicated a lack of encouragement for residents to take showers and inconsistent completion of required documentation.
Some of the Latest Corrective Actions taken by Facilities in Missouri
- Provided education on diet policy, dining-room supervision, and therapeutic-diet preparation (J - F0684 - MO)
- Implemented use of meal photographs showing required diet consistencies for dietary-manager approval before service (J - F0684 - MO)
- Required distribution of menus listing alternatives for regular and mechanically altered diets to all units (J - F0684 - MO)
- Established dietary-manager approval for all food substitutions (J - F0684 - MO)
- Instituted daily briefings on diets and meals between the dietary manager and charge nurse/DON (J - F0684 - MO)
- Posted approved menus on each unit with documented communication of any changes to floor staff (J - F0684 - MO)
- Initiated ongoing reviews of resident diagnoses, diet orders, and aspiration risk (J - F0684 - MO)
Failure to Follow Physician Diet Orders Results in Fatal Choking Incident
Penalty
Summary
A resident with a history of choking and aspiration risk, who was on an assist to dine program and had physician orders for a mechanical soft diet, was served a regular diet tray containing pork loin. The dietary staff had determined that the pork loin was not suitable for mechanical soft diets and had substituted pimento cheese sandwiches for residents requiring this diet. However, due to a miscommunication and error during meal service, the resident received the regular pork loin tray instead of the intended mechanical soft substitution. The resident began choking while eating the meal and became unresponsive, ceasing to breathe. Staff initiated the Heimlich maneuver and CPR, and emergency services were called. Despite these efforts, the resident was transported to the hospital and later expired. The cause of death was determined to be food aspiration leading to respiratory failure and hypoxia. Interviews with staff revealed that the error occurred when the dietary staff and LPN misidentified the correct tray for the resident, resulting in the resident being served food inconsistent with the prescribed mechanical soft diet. Facility policies required that all residents be provided with the prescribed diet as ordered by the physician, and that staff verify the correct tray and diet before serving. In this incident, these procedures were not followed, as the resident's tray was not properly checked against the diet order, and the substitution intended for mechanical soft diets was not provided. The failure to follow physician orders and facility policy directly led to the resident receiving an inappropriate meal, resulting in a fatal choking incident.
Removal Plan
- Education on diet policy, supervision of dining rooms, and preparation of therapeutic diets.
- The facility uses pictures of all three meals showing therapeutic diet consistencies which are sent to and approved by the dietary manager prior to serving any meals.
- Dietary staff send a menu to all units showing alternatives for all regular and mechanically altered diets.
- All food substitutions are approved by the dietary manager.
- The facility holds daily briefings regarding diets/meals between the dietary manager and charge nurse/Director of Nursing (DON).
- Menus are sent to all units and posted on each unit, followed by documented communication from charge nurse/DON to floor staff of any changes.
- The facility reviews all resident diagnoses, diet orders, and aspiration risk.
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