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 did not receive treatment and care in accordance with physician orders and their own preferences and goals, resulting in a failure to meet individualized care requirements.
A resident who required dialysis did not receive safe and appropriate dialysis care and services as needed. The facility failed to ensure that dialysis care was provided according to the resident's needs.
A resident did not receive appropriate care or services to maintain or improve range of motion (ROM) and mobility, and the facility did not ensure interventions were in place to prevent decline unless medically unavoidable.
A deficiency was cited due to the facility's failure to keep an area free from accident hazards and to provide adequate supervision to prevent accidents. The environment did not meet safety standards, and there was insufficient monitoring in the affected area.
A deficiency was cited when an area of the facility was found to contain accident hazards and lacked adequate supervision to prevent accidents. The environment presented risks that were not properly mitigated, and supervision was insufficient to ensure resident safety.
The facility did not ensure pharmaceutical services were provided to meet each resident's needs and failed to employ or obtain the services of a licensed pharmacist, resulting in a lack of required pharmaceutical oversight.
The facility did not promptly inform a resident, the resident's doctor, and a family member about situations such as injury, decline, or room changes that affected the resident, resulting in a failure to meet required notification standards.
An Administrator disclosed a resident's change in code status from full code to DNR to a family member who was not the DPOA, and did so in a public setting at a golf course. This disclosure led to confusion and was acknowledged by the Administrator as a violation of both the resident's privacy and the facility's privacy policy, which require confidentiality of all resident health information.
Surveyors found that the facility did not ensure services were provided in accordance with professional standards of quality. The report did not specify the actions or omissions that led to this deficiency, nor did it provide details about the residents involved.
The facility did not ensure RN coverage for at least eight consecutive hours per day, seven days a week, as required. Review of schedules and staff interviews confirmed multiple days without any RN on duty, with the DON being the only RN and no backup plan in place during absences. Staff awareness of RN coverage was inconsistent, and the deficiency was linked to staffing shortages and changes in the DON position.
Failure to Provide Care According to Orders and Resident Preferences
Penalty
Summary
The deficiency involves a failure to provide appropriate treatment and care according to physician orders, as well as the resident’s preferences and goals. The report indicates that care was not delivered in alignment with established directives or the expressed wishes and objectives of the resident, resulting in noncompliance with required standards for individualized care.
Failure to Provide Safe and Appropriate Dialysis Care
Penalty
Summary
A deficiency was identified regarding the provision of safe and appropriate dialysis care and services for a resident who required such services. The report notes that the facility failed to ensure that the necessary dialysis care was provided in accordance with the resident's needs. Specific details about the actions or omissions that led to this deficiency, as well as information about the resident's medical history or condition at the time, are not provided in the report.
Failure to Provide Appropriate Care for Range of Motion and Mobility
Penalty
Summary
A deficiency was identified regarding the provision of care to maintain and/or improve a resident's range of motion (ROM), limited ROM, and/or mobility. The facility failed to provide appropriate care or services to prevent a decline in these areas, except in cases where a decline was medically unavoidable. The report notes that the necessary interventions to maintain or improve ROM and mobility were not implemented as required.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
A deficiency was identified in the facility's failure to ensure that an area was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment did not meet safety standards, which could contribute to the risk of accidents for residents. Specific actions or inactions leading to this deficiency include the lack of proper hazard identification and insufficient monitoring or supervision in the affected area. No additional details about specific residents, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Maintain Safe Environment and Adequate Supervision
Penalty
Summary
A deficiency was identified due to the failure to ensure that a specific area within the facility was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment posed risks that were not properly addressed, and supervision measures were insufficient to prevent potential incidents. No further details about the specific hazards, the nature of the supervision, or the residents involved are provided in the report.
Failure to Provide Pharmaceutical Services and Licensed Pharmacist Oversight
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of each resident and did not employ or obtain the services of a licensed pharmacist. This deficiency was identified during the survey process, indicating that the required pharmaceutical oversight and services were not in place for residents as mandated by regulations.
Failure to Immediately Notify Resident, Physician, and Family of Significant Events
Penalty
Summary
The facility failed to immediately notify the resident, the resident's physician, and a family member about situations that affected the resident, such as injury, decline, or changes in room assignment. This deficiency was identified based on the lack of timely communication to all required parties when significant events impacting the resident occurred. The report specifically notes the absence of prompt notification following incidents or changes that had a direct effect on the resident's well-being or living situation.
Administrator Disclosed Resident's Code Status in Public, Violating Privacy Policy
Penalty
Summary
The facility failed to maintain the privacy and confidentiality of a resident's personal and medical records when the Administrator disclosed the resident's change in code status from full code to Do Not Resuscitate (DNR) to a family member who was not the resident's Durable Power of Attorney (DPOA), and did so in a public setting. The disclosure occurred while the Administrator was at a golf course, where the resident's family member and another unrelated individual were present. The Administrator informed the family member of the resident's change in code status, which led to a misunderstanding that the resident had experienced a code event. The family member subsequently shared this information with others and went to the facility, only to find the resident awake and confused. The resident's DPOA later stated that they did not want the resident's medical information shared with anyone else, emphasizing that the Administrator should not have disclosed the change in code status to other family members or in a public place. The Administrator acknowledged that she should not have shared the resident's personal medical information with anyone other than the DPOA, recognizing that this action violated both the resident's privacy and the facility's privacy policy. The facility's policy and federal law require that all resident information be kept confidential and only disclosed in accordance with privacy regulations.
Failure to Meet Professional Standards of Quality
Penalty
Summary
The facility failed to ensure that services provided met professional standards of quality. This deficiency was identified through surveyor observation and review of facility practices, which revealed that the care and services delivered did not consistently adhere to accepted professional standards. Specific details regarding the actions or omissions leading to this deficiency, as well as information about the residents involved or their medical conditions, were not provided in the report.
Failure to Provide Required RN Coverage
Penalty
Summary
The facility failed to provide the services of a registered nurse (RN) for at least eight consecutive hours per day, seven days per week, as required by their own policy and federal regulations. Review of nurse schedules over a nearly three-week period revealed multiple days with no RN coverage on any shift. Staff interviews showed inconsistent awareness of RN coverage, with some staff believing an RN was present daily, while others, including an LPN and the DON, confirmed that there were days without any RN on duty. The DON was identified as the only RN on staff, and both the DON and Administrator acknowledged that there were several days without RN coverage, particularly during a change in DON. The facility census at the time was 39 residents, and the DON was also the only RN available, with no clear plan for coverage when the DON was unavailable. Staff were sometimes not informed when there was no RN on duty. The lack of RN coverage was confirmed for specific dates, and the issue was attributed to staffing shortages and transitions in the DON position. The report does not mention any specific residents affected or detail any immediate clinical consequences resulting from the lack of RN coverage.
Some of the Latest Corrective Actions taken by Facilities in Missouri
- Provided in-service education for all staff on elopement, check, and door-monitoring policies (J - F0689 - MO)
- Updated elopement risk and Code White procedure books with current risk assessments and procedures (J - F0689 - MO)
- Adjusted alarmed fire and exit door alarms to increase volume for prompt staff recognition (J - F0689 - MO)
- Established ongoing alarmed-door and check audits (J - F0689 - MO)
Failure to Prevent Elopement and Provide Adequate Supervision
Penalty
Summary
A resident with a history of schizophrenia, bipolar disorder, Alzheimer's disease, and vascular dementia, who was assessed as being at risk for wandering and elopement, exited the facility through an alarmed fire exit door without staff knowledge. The resident was ambulatory with a wheelchair, had a severely impaired cognition, and had recently exhibited aggressive behavior, resulting in an order for 15-minute checks. However, staff failed to complete and document the required 15-minute checks during the relevant time period. The door alarm intended to alert staff to unauthorized exits was not loud enough to be heard until staff were already partway down the hall, as confirmed by multiple staff and resident interviews. Neither the resident's roommate nor another resident on the same hall heard the alarm, and staff only became aware of the resident's absence when a call light was noticed and the resident was found missing from their room. The resident's wheelchair was found by the exit door, and the alarm was only heard after staff began searching for the resident. The resident was later found outside the facility by a local citizen, having sustained multiple serious injuries including facial fractures and a subdural hemorrhage. The timeline and interviews indicate that the lack of timely supervision, failure to perform required checks, and insufficient alarm volume contributed to the resident's unsupervised exit and subsequent injury.
Removal Plan
- Conduct an investigation and notify appropriate parties including the police.
- Provide in-service education for all facility staff including elopement policies, check policies and door monitoring policies.
- Complete elopement risk assessments for all residents.
- Update the elopement risk and code white procedure books with current risk assessments and code white procedures.
- Adjust alarmed, fire, exit door alarms to increase the volume of the alarm for staff to recognize the alarm promptly.
- Perform alarmed door audits and check audits and continue ongoing audits.
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