Missouri Slope

In the surveyor’s words

From the most serious findings on record at Missouri Slope, in the surveyor’s own words.

• Actual harm, isolatedF600Oct 15, 2024

  Based on review of the facility reported incident and investigation reports, record review, review of facility policy, and staff interview, the facility failed to ensure residents remained free from mental and/or physical abuse for 1 of 1 sampled resident (Resident #1) who was witnessed receiving physical and verbal abuse. Failure of facility staff to immediately report a witnessed incident of staff to resident abuse to the appropriate supervisor delayed the removal of the accused abuser, the start of the facility investigation, and assessment of the resident for injury. […]

• Actual harm, isolatedF689Jun 12, 2024

  Based on record review, review of the facility reported incident (FRI), review of facility policy, and resident and staff interviews, the facility failed to prevent accidents for 1 of 1 sampled resident (Resident #1) who sustained a fall with fracture. Failure to utilize the whirlpool seat belt resulted in an avoidable fall and fracture for Resident #1 and placed all residents at risk for falls and/or injuries. This citation is considered past non-compliance based on review of the corrective actions the facility implemented immediately following the incident. Findings include: Review of the facility policy titled Bathing Procedure occured on 06/12/24. The policy, dated November 2023, stated, Resident Safety - Safety Strap Usage Whirlpool: Transfer resident to whirlpool seat. […]

• Actual harm, isolatedF760Feb 16, 2023

  Based on review of information provided by the complainant, facility reported incident investigation, record review, and staff interview, the facility failed to ensure residents remained free from significant medication errors for 1 of 1 sampled resident (Resident #167) who failed to receive an ordered medication on multiple days. Failure to administer medication according to a physician's order may have contributed to high sodium levels and resulted in the resident's hospitalization . […]

• Actual harm, isolatedF760May 11, 2022

  Based on information provided by the complainant, record review, review of facility policy, and staff interview, the facility failed to follow professional standards for medication administration for 1 of 1 resident (Resident #3) who required hospitalization as a result of a significant medication error. Failure of staff to administer medications using professional standards and facility practice resulted in a significant medication error which required an avoidable hospitalization for Resident #3. […]

• No harm, potential for more than minimal, patternF880May 14, 2026

  Based on observation, record review, review of facility policy, and staff interview, the facility failed to follow standards of infection control and prevention for 4 of 21 sampled residents (Resident #50, #61, #139, #154) and 1 supplemental resident (Resident #30) observed during cares. Failure to practice infection control standards related to glove use, hand hygiene, catheter care, equipment disinfection, and enhanced barrier precautions (EBP) has the potential to spread infection throughout the facility. Findings include: Review of the facility policy titled Isolation, Standard Precautions, and Enhanced Barrier Precautions occurred on 05/14/26. This policy, revised December 2025, stated, . […]