Inspection Reports for
Cotton Point Living Center

The complaint investigation substantiated that Resident #2 physically abused Resident #1 on 07/23/25, causing a fractured hip. The facility took immediate corrective actions including notifying police, hospitalizing both residents, and staff education. The incident was reported to the Public Administrator and guardians.

The facility failed to ensure Resident #1 was free from physical abuse when Resident #2 pushed him/her down causing injury. The facility immediately investigated, notified authorities, and in-serviced staff on abuse policies. Resident #1 was hospitalized and returned post-surgery; Resident #2 was transferred to a psychiatric facility.

The facility failed to maintain a safe, clean, and comfortable homelike environment, with multiple observations of dirt, grime, exposed sheetrock, peeled paint, and missing vent covers in resident rooms. Maintenance and cleaning issues were noted, including unclean wheelchairs and equipment.

The facility was found deficient in maintaining a safe, clean, and homelike environment; conducting timely criminal background and employee disqualification list checks; completing and transmitting resident assessments; following physician orders for medications and treatments; maintaining residents' nutritional status; reconciling narcotics properly; ensuring appropriate diagnoses for psychotropic medication use; and storing and distributing food under sanitary conditions.

Complaint #MO00248600. The complaint was substantiated as the investigation confirmed Housekeeper A used Resident #1's bank card without permission. Police are pursuing charges against Housekeeper A.

The facility failed to protect Resident #1 from misappropriation of property when Housekeeper A used the resident's bank card for personal use. The incident was investigated, police were notified, and disciplinary actions were initiated. Staff were re-educated on abuse prevention policies and restitution was made to the resident.

The visit was complaint-related, focusing on allegations of improper management of resident funds, including failure to separate funds, unauthorized withdrawals, untimely refunds, and failure to provide final accounting upon discharge or death. Substantiation status is not explicitly stated.

The facility failed to ensure resident funds were properly managed, including holding resident funds in the operating account, not providing timely refunds to residents, making unauthorized withdrawals without written consent, and failing to reconcile resident trust fund accounts monthly. Additionally, the facility did not provide timely final accounting of resident funds upon discharge or death.

Complaint #MO240597 regarding misappropriation of Resident #1's bank card by CNA A. The complaint was substantiated with evidence including bank statements and CNA admission. CNA A was arrested and terminated.

The facility failed to ensure one resident was free from misappropriation of property when CNA A used the resident's bank card for personal use. The facility investigated, notified authorities, terminated CNA A, and reimbursed the resident.

The facility failed to provide adequate resident care for ADLs, as nine sampled residents and two non-sampled residents did not receive the minimum of two showers per week. Observations and interviews confirmed residents often missed scheduled showers, resulting in unkempt and greasy hair. The Director of Nursing and Administrator confirmed expectations for twice-weekly showers and proper documentation.

The facility was found deficient in maintaining resident dignity during wound care, completing significant change MDS assessments timely, providing adequate bathing care for multiple residents, ensuring a complete hospice coordinated plan of care, implementing fall prevention interventions and monitoring, and properly managing controlled substances including accurate documentation and secure storage.

Complaint #MO214262 regarding non-functional call light system affecting resident safety and ability to summon assistance.

The facility failed to maintain a working call light system in residents' rooms and bathrooms, affecting 13 residents. Observations and interviews confirmed non-functional call lights, and maintenance records showed unresolved issues with the call light system.

The facility was found deficient in multiple areas including failure to notify residents of survey results availability, inaccurate advance directives documentation, failure to notify the Ombudsman of hospital transfers, incomplete care plans, failure to follow physician medication orders, inadequate documentation and monitoring of fluid restrictions, lack of pharmacist recommendations implementation, and failure to provide pneumococcal vaccine education and documentation.