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
Failure to Address PTSD Triggers and Supportive Interventions: The facility did not identify, assess, or include trauma history, triggers, or non-pharmacological interventions in the care plans for three residents with PTSD. One resident had documented trauma, abuse history, nightmares, irritability, and anxiety; another reported recurring bad dreams and triggering resident behaviors; and a third had PTSD with psychotropic medications and observed mood changes and distractibility. Staff interviews confirmed PTSD care plans should include triggers and interventions, but the plans did not reflect those needs.
Failure to issue emergency discharge notice: A resident was sent to the hospital for uncontrolled pain and then told the facility would not accept the resident back because the acuity of care was higher than anticipated. The record contained no documentation of an emergency discharge notice, and the DON and Administrator stated the resident’s needs could not be met and no written discharge was issued.
Failure to provide timely CPR and EMS activation for a resident with conflicting code status documentation. A resident admitted for respite care with Hospice services was documented as Full Code in the chart, while other records referenced DNR status. When the resident was found unresponsive, staff were confused about the code status, CPR was delayed, and there was disagreement among the DON and LPNs about whether a signed DNR was present before life-saving measures were started.
A resident’s right to choose an attending physician was not honored when the facility changed the resident’s PCP from Physician A to Physician B after discontinuing services with Physician A. The resident was cognitively intact and stated he/she wanted to stay with Physician A but did not have a choice. Social services documented the PCP change and later asked if the resident wanted to return to Physician A when that physician resumed practice at the facility.
Infection prevention and control was deficient when staff failed to follow EBP and hand hygiene practices during resident care. An LPN provided wound care to one resident with a pressure ulcer and catheter without a gown, missed hand hygiene opportunities, placed wound care supplies directly on the bed without a protective barrier, and did not change gloves or clean hands between wound care tasks. Another resident with a feeding tube and catheter received tube feeding assistance without a gown, and the LPN said he/she did not know the resident was on EBP.
Facility staff limited residents to two condiment packets per meal and allowed staple foods such as cold cereal, brown sugar, and cottage cheese to run out, despite policy requiring resident preferences to be honored and staple inventory to be maintained. Three residents with cognitive and psychiatric diagnoses reported being denied requested condiments or food items, including butter, ketchup, parmesan cheese, and cereal, and one resident was observed receiving fewer condiments than requested.
Failure to Address PTSD Triggers and Supportive Interventions
Penalty
Summary
The facility failed to identify, assess, and provide supportive interventions for three residents with PTSD. The facility policy titled, Policy and Procedure PTSD, required identification, assessment, care planning, service delivery, documentation, and follow-up for residents with a history of trauma and/or PTSD to promote safety, dignity, psychosocial well-being, and quality of life. However, the care plans for the three sampled residents did not include trauma history, triggers, or non-pharmacological interventions related to PTSD or related behaviors. One resident had diagnoses including PTSD, major depressive disorder, schizoaffective disorder depressive type, and suicidal ideations. The resident’s trauma informed care assessment showed the resident experienced a traumatic event, had nightmares, avoided reminders, felt numb or detached, and felt guilty. Psychiatric notes documented a history of physical and sexual abuse, substance abuse, and increased irritability and yelling at staff. During observation and interview, the resident appeared fidgety and anxious, avoided eye contact, became quiet when discussing the past, and stated that loud people were triggering and that nightmares occurred sometimes. The care plan did not include goals for psychosocial or mental health needs, trauma history, triggers, or non-pharmacological interventions. A second resident with PTSD and schizoaffective disorder bipolar type had an order for prazosin for nightmares, but the care plan did not address trauma history, triggers, behaviors, goals for psychosocial or mental health needs, or non-pharmacological interventions. During observation and interview, the resident was tearful, fidgety, and anxious while discussing nightmares, church leaders, mental health providers, and police, and stated that bad dreams were recurring, some resident behaviors were triggering, and that someone to talk to about triggers would help. A third resident with PTSD, anxiety, bipolar disorder, and cognitive impairment had psychotropic medications ordered for mood and PTSD, but the care plan did not address trauma history or triggers. During observation, the resident was very distracted, fidgety, and had rapid mood changes during conversation. Staff interviews confirmed that PTSD care plans should include triggers and non-pharmacological interventions, but the three residents’ plans did not reflect those needs.
Failure to Issue Emergency Discharge Notice
Penalty
Summary
Facility staff failed to provide an appropriate emergency discharge notice for Resident #1 when the resident was discharged to the hospital and then not allowed to return to the facility. The resident’s face sheet showed admission to the facility and discharge to the local hospital on 5/20/26, and the progress notes documented that the resident was discharged back to the hospital at 11:48 A.M. for uncontrolled pain. Review of the resident’s medical record did not contain documentation of an emergency discharge notice issued to the resident. During interviews, the DON stated the facility was not informed of the full acuity of care and believed it could not meet the resident’s needs, and the Administrator stated the resident’s acuity was much higher than anticipated, the resident was sent to the hospital, and the hospital social worker was told the resident would not be permitted back because of the level of care needed; the Administrator also stated no written discharge was issued.
Failure to Provide Timely CPR for a Full Code Resident
Penalty
Summary
The facility failed to contact EMS and failed to initiate and maintain CPR in a timely manner for one resident who was documented as Full Code. The resident was admitted for respite care with Hospice services in place, had a blank advance directive section on admission, and the record also contained conflicting code status documentation, including a Hospice record showing no DNR order and a care plan indicating DNR. The resident’s progress notes described a decline with fever, watery stool, draining feeding from the mouth, low blood pressure, a pulse of 35, and later unresponsiveness. On the morning of the event, staff documented that the resident was found unresponsive at 8:31 A.M. The note states that family could not be reached, the DON was informed, 911 was called, and staff started CPR on the floor until paramedics arrived and took over. The resident was pronounced dead at 9:01 A.M. The record also showed an Outside the Hospital Do-Not-Resuscitate Order signed by the physician, but staff interviews described confusion about whether the resident was Full Code or DNR at the time of the emergency. During interviews, the DON stated the resident remained Full Code unless a DNR document from Hospice was present and said life-saving measures were to be done until EMS were onsite if no DNR document existed. LPN A stated the resident’s computer profile showed DNR and that the DON told him/her to start CPR, but he/she delayed action and said there was no official copy of the DNR in the facility until after the resident had passed. LPN B stated that when he/she checked the chart, the resident was Full Code, there was no DNR form located, and CPR should have been started immediately. The Medical Director also stated staff were required to do CPR unless the signed DNR document was present and that CPR should have been started in this situation.
Resident Physician Choice Not Honored
Penalty
Summary
The facility failed to honor residents’ right to choose their attending physician when it discontinued services with Physician A, who had been providing care to 30 residents. Three residents from the sample were reviewed, and one resident who was cognitively intact stated a desire to continue care with Physician A. Instead, on 03/25/26, social services informed the resident that the primary care physician would be changed from Physician A to Physician B, and the change-of-PCP paperwork was signed. The resident’s annual MDS dated 03/04/26 showed the resident was cognitively intact. Social service documentation later noted that the resident was told Physician A would be returning to practice in the facility and was asked whether the resident wanted to go back under that physician as PCP; the resident agreed. During interview, the resident stated he/she did not want to change to Physician B and wanted to stay with Physician A, but did not have a choice. The Administrator stated she expected resident rights to be honored and the resident rights policy to be followed as written.
Infection Control Failures During Wound Care and EBP Care
Penalty
Summary
Provide and implement an infection prevention and control program was deficient when facility staff failed to follow infection control practices during wound care and care for residents on Enhanced Barrier Precautions (EBP). The facility’s policy stated that EBP requires gown and glove use during high-contact care for residents with wounds or indwelling medical devices, and that hand hygiene must be performed even when gloves are used. The facility also had no policy directing staff on when to place a barrier before wound care supplies were set down. One resident had a stage two pressure ulcer and an indwelling catheter. During observation, an LPN provided wound care without a gown, left the room without performing hand hygiene, returned with wound care supplies and placed them directly on the bed without a protective barrier, and did not wash hands before applying gloves or put on a gown before wound care. The LPN cleansed the wound and applied the clean bandage without changing gloves or performing hand hygiene between tasks. The resident’s catheter bag and tubing were also observed touching the floor. The LPN stated he/she did not know where the gown and gloves were located, did not notice the EBP sign on the door, and acknowledged that placing wound care items directly on the bed without a protective barrier could create an infection control issue. A second resident had severe cognitive impairment, a feeding tube, and an indwelling catheter. Observation showed no EBP signage on the room entrance, and an LPN provided tube feeding assistance without wearing a gown. The LPN stated he/she did not know the resident was on EBP and was not trained to use a gown when providing tube feeding assistance. The administrator and DON stated staff were directed to wear a gown and gloves for residents on EBP and that wound care supplies should be placed on a protective barrier, with hand hygiene performed before gloving, when gloves are changed, and before exiting the room.
Resident Choice and Dietary Preference Restrictions
Penalty
Summary
The facility failed to honor residents’ rights to make personal choices regarding dietary preferences by limiting condiment packets and allowing staple items to run out. Facility policy stated that residents’ personal choices and individual preferences were to be considered, and that seven days of staple inventory should be maintained under normal operating procedures. Despite this, staff limited residents to two packets of each condiment per meal, and the facility depleted inventory of cold cereal, brown sugar, and cottage cheese. This affected three of six sampled residents in an 80-resident census. Resident #1 had dementia, bipolar disorder, PTSD, and schizoaffective disorder, and his/her care plan directed staff to provide opportunities to make simple choices in daily life. The resident reported that staff limited condiments, did not ask residents who did not request condiments on the menu whether they wanted them, and told residents butter was only provided with toast. During observation, the resident requested multiple condiments and received some items but not others, and became disappointed when parmesan cheese was unavailable for spaghetti. Resident #2, who had schizophrenia, major depressive disorder, mild intellectual disabilities, and nutritional problems, reported that cold cereal and brown sugar regularly ran out and that residents were limited to two condiment packets per meal; the resident also requested two butter packets but received one. Resident #3, who had anxiety and depression and impaired cognition, reported frustration with the two-packet condiment limit and said staff denied additional ketchup when requested.
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Compliance trends in Missouri
Data through Mar 2026Comparisons below measure the most recent period Apr 2025 – Mar 2026 against the prior period Apr 2024 – Mar 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): Apr 2025 – Mar 2026 vs the prior period Apr 2024 – Mar 2025. Only tags with at least 20 citations in both periods are shown.
Severity movers
Tags whose average scope/severity shifted the most: Apr 2025 – Mar 2026 vs the prior period Apr 2024 – Mar 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: Apr 2025 – Mar 2026 vs the prior period Apr 2024 – Mar 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 Apr 2025 – Mar 2026 vs the prior period Apr 2024 – Mar 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. Apr 2025 – Mar 2026 vs the prior period Apr 2024 – Mar 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
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release July 29, 2026) and official state health department websites — never guesswork.
Some of the Latest Corrective Actions taken by Facilities in Missouri
- Implemented additional window-security interventions facility-wide to help prevent elopement through windows (J - F0689 - MO)
- Secured the courtyard picnic table to the concrete patio to reduce access to climbing aids that could facilitate elopement (J - F0689 - MO)
- Educated staff on the resident elopement policy, identifying residents at risk for elopement, and intensive monitoring procedures to strengthen preventive supervision practices (J - F0689 - MO) (J - F0689 - MO)
- Educated staff on documentation requirements for face checks and window security to support consistent completion and recording of required safety checks (J - F0689 - MO)
- Repaired the magnetic locks to restore effective door security and reduce elopement risk (J - F0689 - MO)
Failure to Perform 15‑Minute Safety Checks Allows Elopement Through Window and Roof
Penalty
Summary
The deficiency involves the facility’s failure to provide protective oversight and complete ordered 15‑minute safety checks for a known elopement‑risk resident, resulting in an undetected elopement through the resident’s room window. The resident had multiple psychiatric and behavioral diagnoses, including schizoaffective disorder, psychoactive substance abuse, suicidal ideations, mood disorder, ADHD, opioid abuse, anxiety disorder, and insomnia due to another mental disorder. The resident’s PASRR and care plan documented a long history of mental health issues, substance use, homelessness, prior overdoses, abuse history, and a need for ongoing psychiatric care, low‑stimulation environment, consistent routines, and environmental supports to prevent elopement. Facility assessments, including elopement risk evaluations, identified the resident as at risk for elopement, with a documented history of elopement from prior secured facilities and from home, as well as prior elopement from this facility shortly after admission. The facility’s own elopement and intensive monitoring policies required systematic identification and monitoring of residents at risk for elopement, including intensive monitoring and 15‑minute checks for residents with poor impulse control or elopement ideation. The resident’s elopement risk evaluation showed an increasing risk score over time, and nursing notes documented the resident’s agitation, drug‑seeking behavior, difficulty with redirection, and multiple attempts to get out the door. Staff documented that the resident was on intensive monitoring with every 15‑minute face checks, and the care plan called for completion of elopement risk assessments and face checks/intensive monitoring. On the day of the incident, staff recognized that the resident was “spiraling,” irritated, and had verbalized intent to run away and had attempted to open a door earlier in the day. Despite this, the 15‑minute checks were not consistently or timely completed as ordered, and staff responsible for the checks acknowledged being behind on face checks due to a busy day and documenting checks when they had time rather than at the required intervals. During the period when the resident was supposed to be under 15‑minute face checks, the resident used a metal watch band to loosen and remove the screws from a rubber security block in the windowsill, slid open the side window, pushed out the screen, and exited into a fenced courtyard. The resident reported that it took about an hour to remove the block and open the window and that he closed the curtain when staff entered the room so they would not notice his actions. Staff performing checks reported that they completed face checks by opening the door and seeing if the resident was in the room, without observing what the resident was doing. After exiting into the courtyard, the resident moved a picnic table next to the building, stood on it, climbed onto the roof, crossed the roof, jumped down into an open area outside the fenced courtyard, and walked several blocks down city streets. Facility staff were unaware the resident had eloped until an off‑duty employee saw the resident walking in pajamas and a coat and notified the facility, and a police officer subsequently made contact with the resident, who admitted leaving the facility through the window and walking away.
Removal Plan
- Transferred Resident #1 to the hospital by ambulance per the resident's request after the elopement event
- Placed Resident #1 on one-on-one observation for safety upon return to the facility
- Notified the resident's guardian and physician of the elopement
- Arranged psychiatric services evaluation for Resident #1
- Implemented additional interventions to ensure the security of Resident #1's window as well as all windows in the facility
- Secured the courtyard picnic table to the concrete patio
- Educated all staff regarding the resident elopement policy, residents at risk for elopement, and intensive monitoring procedures
- Educated staff on documentation requirements for face checks and window security
Failure to Supervise Exit-Seeking Resident After Door Lock Failure Resulting in Elopement
Penalty
Summary
The deficiency involves the facility’s failure to ensure a known elopement-risk resident received adequate supervision and protection from accident hazards when the secured unit’s magnetic door locks and alarms were not functioning. The resident had multiple mental health and cognitive diagnoses, including schizoaffective disorder bipolar type, bipolar disorder, vascular dementia, anxiety disorder, impulse disorder, severe memory impairment, and was only oriented to self. A quarterly MDS indicated the resident had a history of wandering throughout the unit, entering other residents’ rooms, and exit-seeking behaviors. The resident’s care plan identified risk for wandering and elopement and directed staff to engage the resident in purposeful activity, identify times when wandering/elopement was more prevalent, and schedule regular walks. On the day of the incident, a repeat BIMS documented that the resident was not cognitively intact. Later that day, nursing notes showed the resident verbally expressed a desire to leave the facility, continued to pack belongings, pressed emergency exit doors, and wandered into other residents’ rooms. Staff initiated frequent visual checks in response to these behaviors. Around 6:00 P.M., the magnetic locks on the main floor dementia unit lost power, and the resident exited the unit via a stairwell and reached the sidewalk before being quickly returned to the unit by staff. The Administrator was notified of the malfunction and arrived on-site, attempted to restore the locks, and contacted the repair company. The Administrator instructed the LPN to ensure the resident remained within line of sight at all times until the magnetic locks were repaired, and the LPN and CMT monitored the doors and the resident from the unit dining room. Despite these instructions and the known door-lock failure, the resident was left unsupervised. After the first elopement, staff, including the LPN, CMT, and CNA, reported they tried to keep the resident in constant view and checked on the resident every few minutes. However, the CMT left shortly after the end of the shift, and the CNA was occupied preparing for the next smoke break. The LPN, who had been assigned to maintain visual oversight of the resident and the unsecured doors, went to the restroom for approximately two minutes without arranging coverage, even though the Administrator remained in the building and the CNA was present on another hall. When the LPN returned, the resident was no longer in the dining room, and a search revealed the resident had eloped a second time. The resident remained unaccounted for until the following afternoon, when the resident was found on a public transit system in a major metropolitan area and later evaluated at a hospital with no injuries identified. The facility’s internal investigation concluded there was a failure in the magnetic door locking system and in adherence to established policies and procedures, and that the facility was aware of ongoing door lock issues and the resident’s exit-seeking behaviors but failed to provide appropriate protective oversight, which directly contributed to the resident’s elopement. The Administrator later stated that nursing staff had documentation from the previous facility indicating the resident was an elopement risk since the morning of admission, several hours before the resident arrived. The Administrator indicated there were only 15 residents on the unit with an LPN, CMT, and CNA assigned, and expressed that the LPN should have had time to review the admission information and communicate with the sending facility. The Nurse Practitioner reported an expectation that staff would have been aware of the resident’s exit-seeking behaviors and would have provided intensive monitoring after the first elopement, particularly given the resident’s need for a locked environment and the failure of the magnetic locks. The Administrator also stated that the event was preventable because the resident had two elopements within an hour, staff knew the magnetic locks were not working properly, and the LPN had been specifically instructed to keep the resident in line of sight until the locks were verified as working.
Removal Plan
- Educate all staff on intensive monitoring of residents, when to notify management, abuse and neglect, and elopement.
- Complete elopement evaluations on all residents to ensure no other residents are at risk.
- Repair the magnetic locks.
- Suspend and terminate Licensed Practical Nurse (LPN) A.
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