Marshfield Care Center: Medication Delays for New Admits - MO
The administrator said the contract with that pharmacy runs through November. The facility is hoping to switch to another one because, in the administrator's own words, "this one is just not working out."
When the inspector asked what the facility's policy requires when a medication isn't available, the administrator said he or she wasn't sure.
The inspection was a complaint investigation, conducted September 10, 2025. Inspectors found that the facility's medication supply system was failing new residents at the point they are most vulnerable: the first hours and days after admission from a hospital.
The process works like this, according to the Director of Nursing. When a new resident arrives, a nurse pulls the discharge orders from the hospital, calls the physician to review the medications, enters the orders into the electronic health record, and faxes the medication list to the pharmacy in Kansas City. If a medication happens to be stocked in the facility's on-site emergency kit, a nurse or medication technician can pull it immediately. If it isn't, staff notify the physician and wait. The wait, the Assistant Director of Nursing said, is typically 24 to 48 hours. Sometimes longer.
For narcotics, including pregabalin, a signed prescription is required before the pharmacy will fill the order at all. The physician handles that. How quickly that prescription gets signed, transmitted, and filled is a separate question the inspection report does not answer.
The Medical Director, interviewed at 5:10 in the afternoon on the day of the inspection, was direct about what he or she found. "There are some processes that need to be addressed and changed," the Medical Director said. The facility, the Medical Director acknowledged, is having difficulty receiving resident medications in a timely way. The expectation, as the Medical Director described it, was that staff would call when a new resident arrived, go over the medications together, and then call again if anything couldn't be obtained. The Medical Director said he or she expected staff to follow orders and, when medications weren't available, to call so other options could be discussed.
Whether that expectation was being met consistently is not something the inspection report resolves. What it does resolve is that three different nursing leaders, the Medical Director, and the Administrator all described a system in which a new resident could arrive at the facility, have a full list of prescribed medications, and then wait an unknown number of hours or days for those medications to actually appear.
The inspection cited the deficiency at a level of minimal harm or potential for actual harm. It affected some residents.
That designation sits at the lower end of the federal harm scale, but the population it applies to is not low-risk. Residents admitted to a rehabilitation and healthcare facility from a hospital are often there precisely because they are medically fragile. The medications on a hospital discharge list are not suggestions.
The Administrator's acknowledgment that the facility has known about this problem, combined with the admission of not knowing what the facility's own policy requires when a medication can't be obtained, describes something more than a logistics gap. It describes a facility that identified a failure in its medication supply chain, has been managing around it, and has not yet fixed it.
The contract with the Kansas City pharmacy ends in November. Until then, new residents will continue arriving with medication lists and an emergency kit that may or may not contain what they need.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Marshfield Care Center For Rehab and Healthcare from 2025-09-10 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 29, 2026 · Our methodology
MARSHFIELD CARE CENTER FOR REHAB AND HEALTHCARE in MARSHFIELD, MO was cited for violations during a health inspection on September 10, 2025.
The administrator said the contract with that pharmacy runs through November.
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.