Inspection report of JC senior care facility reveals improper medication disposal and storage, former employee speaks out

COLUMBIA, Mo. (KMIZ)

An April inspection report obtained by ABC 17 News from the Missouri Department of Health and Senior Services shows improper medication disposal and storage at Heisinger Bluffs Senior Living in Jefferson City.

A Jefferson City man filed a wrongful death lawsuit last week against the facility with claims of medical negligence, not ensuring employees were properly trained and not properly monitoring her food and water intake. Heisinger Bluffs recently settled a separate 2023 wrongful death lawsuit on May 13.

A lack of clarity around job duties always was present in the report, with employees allegedly not knowing about proper storage and disposal procedures. The report details facility staff failing to dispose of discontinued medications for four residents and destroy medication for two discharged residents.

Heisinger Bluff's Medication Storage policy, is cited in the report as preventing the facility from using any
discontinued, outdated, or deteriorated drugs.

The report goes dates back to Jan. 15 when investigators found the medication room containing Resident 1's medication cards. The cards showed a Remeron prescription that had discontinued in November.

On April 15, Resident 2's medication cards -- located in the medication room -- showed a Trazadone prescription that had ended in October and a Quetiapine prescription that discontinued in January.

Resident 3's medication card also showed a Quetiapine prescription that discontinued in October, according to the report. Resident 4's medication cards for two Haldol prescriptions had discontinued in February, the report says.

Resident 100's medication cards with prescriptions for Divalproex, Trazadone and Memantine showed it discontinued in March, per the report.

Resident 101's medication cards included Sertraline, Medroxyprogesterone and Quetiapine prescriptions with a discontinue date in February.

Christine Keeton, a former Level One Medication Aide at Heisinger Bluffs, echoed what was found by investigators with her own experiencing as an employee. Keeton started in February 2025 and worked until the end of April 2025.

"There was some meds that the name had been marked off the bottle and I thought that was unusual for that to be in a med cart because it didn't belong to any of the residents that I gave medications to," Keeton said. "Each person has their own medication with their own name on it and if their name is not clearly on it, it cannot be given to them."

Keeton also detailed being assigned to duties she was not qualified for.

"Showering, dressing clients, toilet toileting them, none of that I was supposed to be doing," Keeton said.

Keeton said she brought her concerns to higher ups multiple times.

The medication room also contained two baskets of 56 medication cards and a cabinet that contained 12 prescription bottles that were discontinued by the physician or from residents who had been discharged or expired from the facility.

According to the Patient Safety Network, failure to discontinue a medication that a clinician wants to discontinue can result in serious, if not fatal consequences, particularly with high-risk medications. If a medication is discontinued, the patient should be instructed to no longer take the medication.

Under Missouri law, medications need to be destroyed within a nursing facility by a pharmacist and a licensed nurse or by two licensed nurses. When two licensed nurses are not available two workers who have authority to administer medications can also destroy medications, but one has to be a licensed nurse or a pharmacist.

A record of what's destroyed is also required and needs to include the resident's name, date, medication name and strength, quantity, prescription number, and signatures of the individuals destroying the medications.

Following the January and April discoveries, investigators interviewed employees. In the first interview with 'Level One Medication Aide A', the employee said the unit manager is responsible for the discontinued and discharged medications, per the report. According to the report, the Aide said they put expired or discontinued medications in the medication room, but were not allowed to destroy them. The report says the Aide claimed two people are required to destroy medications, usually the unit manager and a nurse.

According to the next interview detailed in the report with 'Certified Medication Technician C', the employee said they were not sure how soon medication is supposed to be destroyed after being discontinued. CMT C said the reason the medications were left in the medication storage room is that the nurse only comes down to the unit once a week, per the report. The CMT C also claimed in the report there is no set schedule that they follow to monitor or check the medication room for medications that need destroyed.

In a third interview in the report, 'Licensed Practical Nurse D' allegedly said they were not aware they were supposed to monitor the medications in the storage room or make sure they are destroyed.

The final interview cited in the report was with the facility administrator. The administrator allegedly told investigators they were not aware of the discontinued medications in the medication storage room. The
administrator said it takes two staff to destroy medications and the nurse and CMT are responsible for making sure that is done.

The administrator explained in the interview that it is their responsibility to oversee it is done, but currently there is no process in place to monitor. The administrator claimed the expectation is for discharged and expired resident medications to be destroyed or sent back to the pharmacy within a week.

The report said all discontinued medications discovered were destroyed by the nurse and CMT during the April 15 visit. All 56 medication cards and 12 prescription bottles in the medication storage
room that had been discontinued were also destroyed.

It was also requested that the Nurse Manager and all CMT's be educated on the expired/discontinued medication policy that requires the medications to destroyed within 30 days. The administrator was tasked with auditing the medication room weekly for four weeks and monthly for three months.

Heisinger Bluffs has not returned multipe requests for comment.