Citations in Missouri
Statistics, citations 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
Medication administration documentation was not completed correctly for two residents. One resident with DM, schizoaffective disorder, depression, anxiety, GERD, hyperlipidemia, neuropathy, and pain had multiple missed doses later signed off on the MAR, including one gabapentin entry that was pre-signed before it was due. Another resident with schizophrenia had multiple missed doses for psychotropic, cardiac, thyroid, eye drop, and other medications, and the paper MAR showed later sign-offs and pre-signing of timolol, gabapentin, and Valium before they were due. Staff and the DON acknowledged that medications were documented after the fact and, in some cases, before administration.
A resident with schizoaffective disorder, MDD, and bipolar disorder became frustrated during medication pass when the routine was delayed and different from usual. The resident became verbally aggressive and charged toward the med room, but staff did not call Code Green when escalation began. A CMT then used a non-approved CPI technique by grabbing the resident by the collar and taking the resident to the ground, resulting in minor facial abrasions and complaints of ankle and toe pain.
Unsecured medication carts, treatment carts, and medication room keys: Surveyors observed medication room keys left in the door lock, treatment carts left unlocked and unattended with resident supplies and insulin pens on top, and medication carts left unlocked or only partially locked near residents. An LPN also left keys unsecured in an open pocket on top of a cart after accessing a controlled medication drawer containing resident narcotic pain medication. Staff interviews confirmed that carts, controlled medication drawers, and medication room doors should be locked when not in use.
Failure to Monitor Water System and Test Pneumonia Cases for Legionella: The facility did not implement its Legionella water management program or infection prevention procedures. Weekly logs did not show cold water temperature monitoring, and observed cold water temperatures were in the 82.1-85.5°F range at multiple sinks and showers. The Maintenance Supervisor did not know the ASHRAE guidance, did not check for sediment or biofilm, and the water management team lacked clinical and administrative members. A third-party water test did not include Legionella, and multiple residents with HCAP/pneumonia, COPD, respiratory failure, and antibiotic treatment had no documentation of Legionella testing.
Unsecured controlled meds and incomplete narcotic counts were found in the medication room. Surveyors observed an unlocked narcotic cabinet, an open lock box with a former resident’s medications, controlled meds left on the counter, and medications belonging to residents who had died, been discharged, or had discontinued orders. The narcotic count sheet also had missing nurse signatures and incomplete shift documentation, and staff stated expired or discontinued meds should have been destroyed.
An LPN left the MCU with only one CNA present, despite a staffing guideline requiring two staff members on the unit at all times. While the LPN was off the unit, a resident with dementia became verbally aggressive with two other residents, covered one resident's mouth, threw a walker at the CNA, and then exchanged swatting and punching with another resident before the CNA separated them. The residents involved had dementia-related diagnoses and cognitive impairment, and one resident later had a UTI identified.
Medication Administration Documentation Not Completed Correctly
Penalty
Summary
The facility failed to follow its Medication Administration Policy and did not ensure timely and correct documentation of medication administration for two residents. The policy required staff to follow the six rights of medication administration, administer medications before documenting them, and report and document refusals or adverse effects. Surveyors found that medication administration records for both residents showed multiple missed opportunities that were later signed off as administered on paper MARs, and in some instances the documentation was entered before the medication was due. One resident had diagnoses including diabetes mellitus, schizoaffective disorder, major depressive disorder, anxiety disorder, GERD, hyperlipidemia, polyneuropathy, and low back pain. Review of the July 2026 eMAR showed multiple missed administrations across several scheduled medications, including atorvastatin, ezetimibe, Farxiga, gabapentin, Invega, lisinopril, mirtazapine, omeprazole, sertraline, clonazepam, topiramate, fiber, and tramadol. The paper MAR printed later showed that a CMT signed off as administering all of the missed opportunities for many of these medications, and also pre-signed gabapentin before the medication was due. The CMT stated that the documentation was completed on the paper MAR after the fact and that staff should never document a medication as given before it was actually administered. The second resident had diagnoses including schizophrenia, and the July 2026 eMAR showed missed administrations for atorvastatin, furosemide, latanoprost, levothyroxine, olanzapine, Paxil, trazodone, brimonidine, Depakote, medroxyprogesterone, timolol, gabapentin, and Valium. The paper MAR received for this resident showed only one page and included signatures indicating that missed doses had been administered, while timolol, gabapentin, and Valium were pre-signed before they were due. Staff interviews confirmed that the internet outage affected documentation, that some staff used hotspots while others used paper MARs, and that the DON directed staff to sign the paper MARs later. The DON acknowledged that staff should not document medication administration before the medication is actually administered and that the residents should have had completed documentation at the time of administration.
Failure to Follow CPI During Resident Behavioral Escalation
Penalty
Summary
The facility failed to follow its CPI policy and behavioral health expectations for a resident with a history of aggression toward staff. The resident had diagnoses including schizoaffective disorder, major depressive disorder, and bipolar disorder, and the MDS showed the resident was cognitively intact but had physical behavioral symptoms directed toward others. The care plan identified negative behaviors such as charging people, seeking revenge, hitting, and tackling, and listed triggers including bullying, stealing, and loss of control. During morning medication administration, the resident became frustrated because the medication pass was slower than usual and different from the resident’s normal routine. The resident repeatedly demanded medications, became verbally aggressive, and approached the medication room doorway. Staff did not initiate a Code Green when the resident began escalating. Instead, the CMT told the resident he/she would document the medications as refused, which further upset the resident. The resident then yelled and charged at the medication room door. When the resident entered the medication room area and the situation escalated, the CMT used a non-approved technique by grabbing the resident by the collar and moving the resident to the ground. The resident sustained an abrasion to the right cheek and right eyebrow and complained of pain to the right ankle and big right toe. Witness statements and staff interviews described that the response did not follow approved CPI techniques and that Code Green procedures were not initiated early in the escalation.
Unsecured medication carts, treatment carts, and medication room keys
Penalty
Summary
The facility failed to ensure medications and biologicals were secured in locked compartments, including controlled drugs, when medication and treatment carts were left unattended and unlocked, medication keys were left in open view, and medication room keys were left in the door lock. The facility policy stated that medications and biologicals are to be stored safely and securely, that access is limited to authorized personnel, and that medication rooms, carts, and supplies are locked when not attended by persons with authorized access. On the 300/400 hall, surveyors observed the medication room keys left in the lock of the medication room door where they were visible to anyone walking by the nurse’s desk. The 300 and 400 hall treatment carts were also observed in a hallway area, unlocked and unattended, with resident treatment supplies inside, including bandages and prescription ointments and creams. An open caddy on top of the treatment cart contained toothbrush holders with resident insulin pens. These same conditions were observed again later, with no staff at the nurse’s desk and the carts still unlocked and unattended. Surveyors also observed two unlocked medication carts in a common area near the dining room while CMT staff were providing medications to residents. One resident was in the area near the carts. An LPN removed keys from an open pocket on top of a medication cart, unlocked the cart and controlled medication drawer containing resident narcotic pain medication, then returned the keys to the open pocket and walked away leaving the keys unsecured. Another CMT partially locked a cart and returned to the dining room, and another did not lock the cart at all. Staff interviews confirmed that medication carts, treatment carts, controlled medication drawers, and medication room doors should be locked when not in use, and that some staff were leaving keys in the cooler bag or in the medication room door.
Failure to Monitor Water System and Test Pneumonia Cases for Legionella
Penalty
Summary
The facility failed to implement its infection prevention and control program and its Legionella water management program. The facility policy required scheduled actions for hot water tanks, faucets, showerheads, and hoses, and described a water system with hot water heaters, cold water distribution, decorative fountains, cooling towers, and multiple plumbing fixtures. However, the weekly water temperature logs for May, June, and July 2026 did not show cold water temperatures being checked. During observation on 07/30/26, cold water temperatures measured at multiple locations were documented between 82.1 degrees F and 85.5 degrees F, including resident rooms, men’s bathrooms, and men’s spas. The Maintenance Supervisor stated he was not sure of everything the facility did to monitor for Legionella, did not know what the ASHRAE guidelines were, did not check water heaters or faucets for sediment, biofilm, or scaling, and said staff monitored hot water but not cold water temperatures. He also stated the water management team consisted only of maintenance staff and that no clinical or administrative staff were on the team. The facility also did not have the third-party water testing company test for Legionella. The service report dated 06/03/26 showed the company did not test for Legionella. The facility policy on Legionella stated the water management plan required actions to prevent Legionella and other bacteria from developing in the water delivery system, but the record showed no evidence that the facility implemented testing protocols or control measures consistent with CDC and ASHRAE guidance. The Infection Preventionist stated she was not part of the water management team and had not tested any residents diagnosed with pneumonia for Legionella. The Assistant Administrator stated the facility had not tested residents diagnosed with pneumonia for Legionella and that physicians thought testing was unnecessary. The facility also failed to develop and follow procedures consistent with CDC guidance to test residents with healthcare-associated pneumonia for Legionnaires’ disease. Review of the records for multiple residents showed diagnoses of pneumonia by chest x-ray and antibiotic treatment, including residents with COPD, pulmonary disease, acute respiratory failure with hypoxia, shortness of breath, cough, and other respiratory conditions. For each of the reviewed residents, the medical record showed no documentation that Legionnaires’ disease testing was performed. The residents reviewed included one resident with pneumonia and cough, another with COPD and acute respiratory failure who was sent to the hospital, and several others with pneumonia treated with antibiotics such as amoxicillin, cefdinir, doxycycline, azithromycin, and amoxicillin-potassium clavulanate. The facility’s infection prevention policy required surveillance and control measures for healthcare-associated infections, but the record showed no documentation that residents with pneumonia were tested for Legionella.
Unsecured controlled medications and incomplete narcotic counts
Penalty
Summary
The facility failed to ensure drugs and biologicals were labeled and stored according to accepted professional principles. During observation of the medication room, the narcotic cabinet padlock was unlocked, and the medication room contained multiple unsecured medications, including controlled substances and discontinued or discharged resident medications. These included sealed bottles of liquid Lorazepam and liquid Morphine belonging to a resident who had died two months earlier, as well as Haloperidol, Zofran, acetaminophen suppositories, Oxycodone tablets, and Clonazepam tablets belonging to residents who had been discharged or whose orders had been discontinued. The medication room also contained a large black lock box left open on the counter with 12 prescription medications for a former resident who had been discharged over four months earlier. RN A stated the resident had not been there for a long time. A cartridge for the secure, computer-controlled medication dispensing cabinet containing eight tablets of Clonazepam 0.5 mg was also found sitting in a plastic bag on the counter, and RN A stated it had been there since it came from the pharmacy and did not have a count sheet. RN A further stated that expired or discontinued medications should have been destroyed by then and that it was a risk for diversion. Review of the narcotic count sheet showed only seven dates with nurse activity and several entries missing required signatures, with some shifts signed by only one nurse or no complete on-duty/off-duty documentation. RN A stated nursing staff should check and sign the narcotic count sheet daily when going on and off shift. The DON and Administrator both stated nurses were expected to complete narcotic counts, sign the sheets for controlled medications in the medication room and refrigerator, and ensure narcotics were disposed of properly. The Administrator also stated medications should be placed into the secure, computer-controlled medication dispensing cabinet when delivered by the pharmacy and that the receiving nurse should verify the count with the delivery person.
Insufficient MCU Staffing During Resident Altercation
Penalty
Summary
The facility failed to provide enough nursing staff on the Memory Care Unit and failed to maintain a licensed nurse in charge on the unit when an LPN left the MCU and CNA A was left as the only staff member. During that time, Resident #1, who had dementia, major depressive disorder, and a history of urinary tract infections, was sitting in the dining room with Residents #2 and #3, both of whom also had dementia-related diagnoses and cognitive impairment. The facility staffing guideline stated that two staff members were required on the MCU from 6:00 A.M. to 10:00 P.M. at all times. While the LPN was off the unit, Resident #1 and Resident #2 began verbally arguing, and Resident #1 covered Resident #2's mouth with a hand. CNA A separated the residents, after which Resident #1 threw a walker at CNA A and a pair of pants fell from the walker. Resident #3 reached down to pick up the pants, and Resident #1 became irritated and swung at Resident #3. Resident #3 swung back, and both residents began swatting at each other until CNA A separated them again. The LPN returned and was notified while walking up the hallway. The facility investigation documented that the residents were assessed and had no injuries, and Resident #1 later had a urine sample showing a UTI. Interviews showed the LPN had asked CNA A to watch the residents while he/she briefly left the MCU to deliver paperwork, leaving only one staff member on the unit. The Administrator stated the LPN was expected to call, text, or use a walkie talkie to get another staff member to the MCU before leaving.
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Compliance trends in Missouri
Data through May 2026Comparisons below measure the most recent period Jun 2025 – May 2026 against the prior period Jun 2024 – May 2025 (two equal 12-month windows). The most recent 2 months are excluded because CMS is still publishing them.
Top tags by month · last 24 months
dashed = still reportingMonthly citation counts for the 5 most-cited tags. The dashed tail is the 2-month reporting lag.
Frequency movers
Biggest change in how often each tag is cited, as a rate per 100 inspections (so it isn't skewed by survey volume): Jun 2025 – May 2026 vs the prior period Jun 2024 – May 2025. Only tags with at least 20 citations in both periods are shown.
Severity movers
Tags whose average scope/severity shifted the most: Jun 2025 – May 2026 vs the prior period Jun 2024 – May 2025. The number is the average severity on the A–L scale (A=0…L=11); the letter is the band it falls in. A rise means the same tag is being cited at a more serious level — note the average can move enough to rank here while staying within the same letter. Same 20-citation minimum applies.
Care domain movers
Citations grouped into CFR care domains — F-tags by their §483 regulatory section (CMS State Operations Manual, Appendix PP) — measured as a rate per 100 inspections: Jun 2025 – May 2026 vs the prior period Jun 2024 – May 2025. Share is the domain's portion of citations this period; avg severity is the mean scope/severity letter and immediate jeopardy the percentage cited at J–L, both over the current period. Domains with at least 20 citations in both periods are shown; the sparkline tracks the last 12 months (left = oldest).
Immediate jeopardies · this period
Citations at the most serious scope/severity — J–L, immediate jeopardy, residents placed at risk of serious harm or death — over Jun 2025 – May 2026 vs the prior period Jun 2024 – May 2025. "Surveys with an IJ" counts distinct health inspections that had at least one.
Survey activity · by month
faded/dashed = still reportingCitations each month split into complaint-driven (unscheduled, triggered by grievances) vs standard surveys — bars, left axis — with the number of inspections as a line on the right axis. Rising inspections signal more scrutiny; a rising complaint share means more off-cycle surveys. The most recent 2 months are still being reported.
Deficiency-free survey rate
Share of health surveys that found zero deficiencies — the odds of a clean survey. Jun 2025 – May 2026 vs the prior period Jun 2024 – May 2025; the most recent 2 months are still being reported (dashed).
Penalties · by month
faded = still reportingTotal civil money penalty dollars imposed on the state's facilities each month — how hard the state is enforcing. The most recent 2 months are still being reported, and penalties often lag citations by several months.
Emerging tags
Tags that weren't established last period but surged — an early warning, distinct from movers (which track already-common tags). Criteria: fewer than 20 citations in the prior period, but at least 10 this period and 2.5× their prior volume. The sparkline shows monthly counts over the last 12 months (left = oldest).
Trusted data from CMS and state health departments
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