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 Immediately Report Abuse Allegations and Injury of Unknown Origin: Staff did not immediately report two resident-to-resident sexual abuse incidents involving one resident touching two others, and staff also did not immediately report bruising of unknown origin on another resident. A CNA redirected the resident during the abuse incidents but did not notify the charge nurse, DON, or Administrator, and an RN and LPN did not escalate the bruising after assessing it and hearing it described as handprint-like. The delayed reporting prevented timely initiation of the abuse investigation process and resident assessment.
A CNA witnessed two incidents of resident-to-resident sexual abuse/inappropriate sexual contact involving a resident with dementia and severe cognitive impairment, including touching one resident’s breasts and reaching under another resident’s blanket, but did not immediately report either event to the charge nurse, DON, or Administrator. The incidents were later discovered in EMR alerts, and the DON stated the facility was unaware of them for about two days because the CNA failed to report them.
The facility failed to maintain an effective grievance process for residents and family members to file grievances verbally or anonymously. Although the Resident Rights and grievance policy allowed oral and anonymous complaints, only small grievance notices were posted, and no grievance forms or grievance box were available at the receptionist area. Residents said they did not know how to file anonymously, the receptionist was unsure how anonymous filing worked, and the DON stated the facility previously had grievance forms and a drop box but they were removed.
Failure to Perform Required Overnight Resident Checks: A resident with a history of falls, confusion, and gait/balance problems was not checked at least every two hours overnight as expected. Staff later found the resident on the floor in the room with the door closed, dried blood on the head, face, and hands, and the resident reported trying to get help after falling while going to the bathroom. The resident was hospitalized with a traumatic head hematoma and traumatic rhabdomyolysis, and the ER noted the blood appeared to have been present for a prolonged period of time.
Improper transfer of a non-weight-bearing resident: Staff transferred a resident who was ordered for Hoyer lift assistance using a two-person stand-pivot transfer instead of the required lift and without a gait belt. The resident reported pain during the transfer and later had bruising, swelling, and a left ankle fracture. Records showed the resident was dependent for transfers and the care plan directed mechanical lift assistance x 2.
A resident with dementia, weakness, hallucinations, and a history of falls was left unattended on the toilet and tried to transfer to a wheelchair without help, falling onto the right side and later found to have a right femoral neck fracture. The resident had a prior fall as well, but the care plan did not document the fall history, fall risk status, or fall interventions. Staff interviews confirmed residents should not be left alone in the bathroom, and the resident was resistive to care and dependent on staff for transfers and toileting.
Failure to Immediately Report Abuse Allegations and Injury of Unknown Origin
Penalty
Summary
The facility failed to ensure staff immediately reported allegations of abuse to administration for two separate resident-to-resident sexual abuse incidents involving three residents. One CNA witnessed Resident #3 inappropriately touch Resident #1’s breasts while Resident #1 was asleep, and later saw Resident #3 reach under Resident #2’s blanket while Resident #2 pushed the hands away and told Resident #3 to stop. The CNA redirected Resident #3 during both incidents but did not immediately notify the charge nurse, DON, or Administrator. The incidents were later identified by the DON through electronic medical record alerts, and the DON and Administrator stated they were not notified when the events occurred. The facility also failed to ensure staff immediately reported an injury of unknown origin for Resident #4. Two CNAs observed multiple bruises, including bruises resembling handprints, while providing care and notified an RN and LPN. The RN assessed the resident and documented bruising of unknown origin, but neither the RN nor the LPN notified the DON or Administrator at that time. The LPN stated the CNAs were discussing the bruises with the RN and therefore did not contact higher management, while the RN did not believe the bruising was concerning because the resident had fragile skin and was on a blood thinner. Because the allegations were not immediately escalated, the facility’s abuse investigation process was delayed, including resident assessment and collection of investigative information. For Resident #4, the DON stated the resident had already been transferred to the hospital before the facility initiated an abuse investigation and could not be assessed as part of the initial investigation. The Administrator acknowledged that facility protocol requiring immediate reporting of abuse allegations was not followed in both events.
Failure to Immediately Report Resident-to-Resident Sexual Abuse
Penalty
Summary
The facility failed to ensure two residents remained free from abuse when a CNA witnessed resident-to-resident sexual abuse/inappropriate sexual contact by another resident and did not immediately report the incidents to nursing management. One resident, who had Alzheimer’s disease and severe cognitive impairment, was observed asleep when another resident intentionally touched the resident’s breasts. About 30 minutes later, the same resident entered a second resident’s room and reached underneath that resident’s blanket in an attempt to touch the resident inappropriately. Both residents had severe cognitive impairment and were unable to provide reliable interviews. The CNA who witnessed both incidents did not immediately notify the charge nurse, DON, or Administrator. Instead, the incidents were later found in EMR alerts, and the DON stated she did not learn of the allegations until approximately two days later. The Administrator stated the CNA should have immediately reported both incidents and acknowledged the facility was unaware of them for about two days because the CNA failed to report them and facility protocol was not followed. The resident identified as the alleged perpetrator had dementia with behavioral disturbance and a BIMS score of 5, indicating severe cognitive impairment. The record also showed prior behavioral issues involving aggression toward staff, but no prior history of sexual behaviors was documented. The investigation record described the resident as touching one resident’s breasts and placing a hand under another resident’s blanket, with the second resident pushing the hand away and telling the resident to stop. The facility’s report also documented that the CNA did not report the events when they occurred.
Ineffective Grievance Process and No Anonymous Filing Option
Penalty
Summary
The facility failed to maintain an effective grievance process for residents and family members to file grievances verbally or anonymously. The facility's Resident Rights stated residents have the right to voice grievances without discrimination or reprisal, and the Grievance - Informal and Formal policy stated grievances may be filed in writing or orally and may be filed anonymously. However, during observation from 6/29/26 through 7/2/26, the facility only had three grievance signs posted, each printed on an 8 1/2 by 11-inch sheet with small font and listing staff contacts, phone numbers, and email addresses. There were no grievance forms or grievance box located at the receptionist area for residents, families, or visitors to file grievances anonymously. During the resident group interview, three alert residents stated they did not know who the grievance officer was or how to file a complaint anonymously. They said they would tell their aide or nurse about a concern with direct care, but preferred to file concerns anonymously because they did not want staff to be mad or upset with them. The receptionist stated he/she was not sure how a resident would file a grievance anonymously and said residents could call the front desk, which would notify the appropriate department while keeping the resident's identity private. The DON stated residents knew they could bring concerns to her or the charge nurses and said the facility previously provided grievance forms and a grievance drop box, but she was not sure why the new company removed them. The Administrator stated the facility posted signs explaining how to file grievances and said residents could file anonymously by using the grievance box located at the receptionist's desk, although the observation showed no grievance box there.
Failure to Perform Required Overnight Resident Checks
Penalty
Summary
The facility failed to ensure the safety of one resident with a history of falls when staff did not routinely check on the resident at least every two hours during the night, as expected by the facility’s policy. The resident had been admitted with gait and balance problems, incontinence, psychoactive drug use, and a history of falls, and the care plan directed staff to anticipate and meet the resident’s needs, keep the call light within reach, and provide a safe environment. The resident was also documented as very confused and walking around the hallway most of the shift on the evening before the incident. On the morning of the incident, staff found the resident on the floor in the resident’s room with the door closed and dried blood on the hair, face, and hands. The resident was unable to say what happened and reported trying to go to the bathroom, not remembering hitting the floor, and crawling around trying to get up but being unable to do so. The resident said the door was closed and guessed no one heard calls for help. The facility’s investigation found that the overnight CNAs left without conducting walking rounds with the oncoming CNA, and the resident was found during rounds at 6:45 A.M. with a large hematoma on the forehead and bleeding. The resident was sent to the hospital and remained there for four days with diagnoses of traumatic hematoma of the head and traumatic rhabdomyolysis. The emergency room physician noted that the blood was completely dried in the resident’s hair and appeared to have been present for a prolonged period of time, and lab results raised concern for rhabdomyolysis related to prolonged downtime. The DON determined that the last checks by the overnight CNAs were at 12:00 A.M. and the last check by the LPN was at 4:00 A.M., rather than every two hours throughout the night.
Improper transfer of a non-weight-bearing resident
Penalty
Summary
The facility failed to ensure that a resident who was non-weight bearing on the left leg and identified in the care plan as requiring a Hoyer lift for transfers received the prescribed transfer assistance. On 05/05/26, CNA A and CMT B performed a transfer without using the mechanical lift or a gait belt, despite the resident’s documented transfer status and the resident’s report that the physician had ordered Hoyer lift use. The resident stated that staff lifted and turned him/her during the transfer and that the resident complained of pain while being moved. The resident’s records showed significant mobility impairment, including dependence on assistance with sit-to-stand and chair/bed-to-chair transfers, lower extremity impairment on one side, and diagnoses including a periprosthetic fracture around the internal prosthetic left knee joint, unsteadiness on feet, and lack of coordination. The care plan in effect at the time directed mechanical lift assistance x 2. Facility policies stated that residents requiring assistance with transfers were to be transferred using a gait/transfer belt or a lift, and that mechanical lift procedures were used for residents unable to independently pivot or transfer. After the transfer, the resident had bruising and swelling to the left knee, lower leg, ankle, and toes. An x-ray of the left ankle showed a fracture, and the resident was sent to the emergency room for further evaluation. Statements obtained during the investigation showed that CNA A knew the resident was a Hoyer lift transfer, while CMT B stated he/she did not know that status and relied on CNA A during the transfer. The facility determined the resident was transferred incorrectly using a two-person transfer instead of the required Hoyer lift.
Failure to Supervise Toileting and Update Fall Care Plan
Penalty
Summary
The facility failed to provide adequate supervision and assistance to prevent an accident for a resident with a history of falls and significant cognitive and functional impairment. The resident had diagnoses including Alzheimer's disease, dementia with psychotic disturbance, history of stroke, muscle weakness, delusional disorder, depression, difficulty walking, hallucinations, history of falling, and communication deficit. The resident's fall risk evaluation identified intermittent confusion, wheelchair use, balance problems, multiple predisposed diseases, and that the resident was at risk for falls. The resident's care plan in use during the survey did not document the resident's fall history, fall risk status, identified risk factors, or fall interventions. On 04/26/26, staff left the resident unattended on the toilet. The resident attempted to transfer from the toilet to the wheelchair without assistance and fell onto the right side. After the fall, the resident had an abrasion to the right elbow and right buttock, guarded the right leg, and complained of pain. The nurse could not assess range of motion because of guarding and refusal. The physician, resident representative, and DON were notified, and x-rays of the right hip, femur, and knee were ordered. The resident was later found to have a nondisplaced impaction fracture of the right femoral neck. The record also showed the resident had a prior fall after admission, including being found on the floor beside the bed with a hematoma to the right side of the head, but the care plan still did not reflect the resident's falls or updated interventions. During interviews, staff stated residents should never be left unattended in the bathroom, and the Administrator said she would have preferred the aide to stay with the resident during toileting. The ADON reported that the resident was resistive to care and had a previous fall, and the NP stated the resident was a fall risk and would not have expected staff to get the resident up to toilet him/her.
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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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