Jefferson City Manor Care: Missed Wound Treatments - MO
The complaint inspection, conducted November 17, 2025, found that a resident had gone without twice-daily treatments ordered by his or her physician on at least November 14 and November 16. The resident said it plainly: staff have not been doing the treatments every shift the way the doctor ordered.
The director of nursing said she had no idea.
When inspectors interviewed the DON that afternoon, she said she was unaware of the resident refusing treatments and that she expected nurses to administer them twice daily as directed. Refusal, though, was not what the resident described. The resident said the treatments simply were not happening.
That distinction matters. A resident who refuses care generates a record, a conversation, a note. A resident whose treatments are quietly skipped may generate nothing at all, which is exactly what inspectors found when they looked at the treatment administration record, known as a TAR. Signatures were missing. Whether the treatments had been given was, in the words of one nurse, uncertain.
Licensed Practical Nurse B told inspectors that the charge nurse is responsible for providing treatments as directed and documenting on the TAR once completed. Then came the admission that defined the inspection: if there are missing documentation or signatures on a resident's TAR, it is uncertain if the treatments were completed.
Uncertain. Not delayed. Not given late. Uncertain, meaning no one could say.
The administrator was more direct. He or she told inspectors that if signatures are missing from the TAR, then the treatment probably wasn't administered. The administrator also said the DON is responsible for conducting weekly audits to catch exactly this kind of gap and address any concerns with the nurses.
The DON, by her own account, had not caught it.
The audits are supposed to be the backstop, the mechanism that catches missed care before it compounds. A wound untreated once is a wound at greater risk. A wound untreated across multiple shifts, across multiple days, is a wound that can deteriorate into something far harder to reverse. The DON acknowledged to inspectors that the purpose of the twice-daily treatments was to reduce the risk of infection.
What the inspection record shows is a facility where the physician ordered twice-daily wound care, the resident went without it on at least two separate days across a three-day span, the nurse responsible for administering it left no documentation, the weekly audit process failed to surface the problem, and the director of nursing learned about it from a federal inspector rather than from her own oversight system.
The administrator and the DON both described the same expectation in their interviews: nurses administer treatments as ordered, nurses document on the TAR when finished. Both described the same accountability mechanism: the DON audits weekly for missing entries. Neither described what actually happens when the audits find nothing because nobody is looking closely enough, or when a resident's chart goes unsigned and no one follows up.
The resident, meanwhile, had been telling staff directly. Not inspectors first. Staff. The treatments were not happening every shift the way the doctor ordered. That is what the resident said on November 17, after days had already passed.
CMS cited the deficiency under F0658, which covers professional standards of care, at a level of minimal harm or potential for actual harm. The citation reflects what inspectors could document, not necessarily the full scope of what the resident experienced across those days with an untreated wound and no one able to say with certainty whether the ordered care was ever given.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Jefferson City Manor Care Center from 2025-11-17 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 1, 2026 · Our methodology
JEFFERSON CITY MANOR CARE CENTER in JEFFERSON CITY, MO was cited for violations during a health inspection on November 17, 2025.
The resident said it plainly: staff have not been doing the treatments every shift the way the doctor ordered.
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.