Webco Manor: Medication Administration Failures - MO
The inspection, triggered by a complaint, identified failures in medication administration that left some residents without doses they were supposed to receive twice daily. Inspectors assigned the violation a level of minimal harm or potential for actual harm, meaning the failures either caused minor harm or put residents at risk of something worse.
The director of nursing, interviewed by inspectors on August 28, acknowledged the problem directly. He or she said residents had not received medications at the required twice-daily schedule. The director also said that when new nurses were hired, they were sent to the CMT supervisor for training and were given practice time in the electronic medical record system. But there was a gap in that process. The director said he or she should have scheduled the infection preventionist for the training as well, and took responsibility for ensuring staff understood both how to administer medications and what to do when something went wrong.
What went wrong, in at least one case, was more than a missed dose.
The administrator, also interviewed on August 28, said that writing a medication order without first notifying a physician was not within a nurse's scope of practice. The standard process, as the administrator described it, was straightforward: if a CMT noticed a discrepancy between a medication and the order on file, they were supposed to notify the charge nurse, who would then contact the physician for clarification. That chain of communication existed for a reason. A nurse who bypasses it and writes an order independently creates a situation where a resident may receive a medication, at a dose or by a route, that no physician has reviewed or approved.
The administrator said staff were expected to follow the five rights of medication administration when giving any medication to any resident: the right resident, the right medication, the right route, the right dose, and the right time. Those five checks are the most basic framework in nursing practice for preventing medication errors. Inspectors found that framework had not held.
The inspection report does not specify how many residents were affected by missed doses or how long the problem persisted before the complaint was filed. It does not name the nurse who wrote the unauthorized order, nor does it describe what medication was involved or whether any resident experienced a physical consequence from receiving it. What the report does make clear is that the failures were not isolated to a single moment. The director of nursing described a training process that had a structural gap, one that existed from the time new staff were hired.
Webco Manor is a nursing facility in Marshfield, a small city in Webster County in southwest Missouri. The inspection was conducted as a complaint investigation, meaning someone, a resident, a family member, or a staff member, contacted regulators with concerns before inspectors arrived.
Medication errors in nursing homes carry consequences that range from minor to fatal depending on what drug is involved and what population is receiving it. Nursing home residents are typically older, often managing multiple chronic conditions, and frequently taking medications where timing and dosage matter significantly. A missed twice-daily medication is not always inconsequential. Neither is a dose administered based on an order that no physician reviewed.
The director of nursing told inspectors he or she was responsible for ensuring staff understood the medication administration process and knew what steps to take when an error occurred. That acknowledgment came during the inspection itself, after the failures had already happened and after a complaint had already been filed.
Training had occurred. Practice in the electronic medical record system had occurred. The CMT supervisor had been involved. But the infection preventionist had not been scheduled for the training, the five rights had not been consistently followed, and at least one nurse had written an order that was not hers or his to write.
The residents who missed their medications twice daily during this period did not have a say in whether the staff caring for them had been fully trained.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Webco Manor from 2025-08-28 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 30, 2026 · Our methodology
WEBCO MANOR in MARSHFIELD, MO was cited for violations during a health inspection on August 28, 2025.
The director of nursing, interviewed by inspectors on August 28, acknowledged the problem directly.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.