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F0689
E

Failure to Search Resident Belongings Allows Illegal Substances in Facility

Salisbury, Missouri Survey Completed on 11-24-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

Staff failed to follow facility policy regarding the search and inventory of a resident's personal belongings upon admission, resulting in the resident bringing prohibited and illegal substances into the facility. The policy required the admission coordinator or designee to complete an initial inventory and ensure no contraband entered the facility, with floor staff under the charge nurse responsible for addressing and removing any items not allowed. On the night of admission, staff did not complete the required search due to being occupied with other incidents, including a resident attempting to elope and multiple admissions, and subsequently did not want to disturb the new resident who had fallen asleep. The resident, who had a documented history of polysubstance abuse, later reported bringing a dab pen containing cannabis concentrate, 20 tablets of Adderall, and bath salts (an illegal synthetic stimulant) into the facility. The resident stated that none of the staff searched their belongings, which were kept in a duffle bag. The resident admitted to consuming some of the substances and sharing them with other residents. Drug testing confirmed that multiple residents tested positive for methamphetamines and THC, and the resident did not have a physician's order for Adderall. Interviews with staff revealed that the required inventory and search process was not completed at the time of admission, and the Director of Nursing and Administrator were unaware that the search had not occurred. Staff acknowledged that belongings should have been kept at the nurse's station until a search could be completed, but this protocol was not followed. As a result, illegal and controlled substances were introduced and distributed within the facility, directly violating facility policy and federal regulations.

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