Inspection Reports for
Cotton Point Living Center
609 SOUTH RAILROAD ST, MATTHEWS, MO, 63867-9751
Back to Facility ProfileDeficiencies (last 7 years)
Deficiencies (over 7 years)
19.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
258% worse than Missouri average
Missouri average: 5.5 deficiencies/yearDeficiencies per year
36
27
18
9
0
Occupancy
Latest occupancy rate
61% occupied
Based on a July 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Complaint Investigation
Census: 60
Deficiencies: 1
Date: Jul 31, 2025
Visit Reason
The inspection was conducted due to a complaint investigation following a resident-to-resident physical abuse incident on 07/23/25, where Resident #2 pushed Resident #1 down, resulting in a fractured hip requiring surgery.
Complaint Details
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.
Findings
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.
Deficiencies (1)
Failure to protect Resident #1 from physical abuse by Resident #2 resulting in injury and immediate jeopardy to resident health or safety.
Report Facts
Residents Affected: 2
Facility Census: 60
Employees mentioned
| Name | Title | Context |
|---|---|---|
| N A | Licensed Practical Nurse (LPN) | Reported details of the resident-to-resident altercation and documented Resident #1's injuries |
Inspection Report
Life Safety
Census: 54
Capacity: 90
Deficiencies: 6
Date: Mar 7, 2025
Visit Reason
The inspection was conducted to assess compliance with the 2012 Existing Edition of the Life Safety Code of the National Fire Protection Association (NFPA) and related fire safety regulations.
Findings
The facility failed to meet several fire safety requirements including ensuring unobstructed means of egress, installation of self-closing devices on doors to hazardous areas, and maintaining hazardous areas free of gaps allowing smoke passage. These deficiencies potentially affected all residents and staff.
Deficiencies (6)
K211 Means of Egress - General: The facility failed to ensure the exit discharge from the main dining room was free of obstructions, as an SUV was blocking the rear exit pathway. This affected all residents and staff.
K223 Doors with Self-Closing Devices: The facility failed to ensure doors to hazardous areas had self-closing devices installed and those present did not close and latch properly. This affected all residents, visitors, and staff.
K321 Hazardous Areas - Enclosure: The facility failed to maintain hazardous areas free of gaps allowing smoke passage, including a laundry room door with a half inch gap. This affected all residents and staff.
A2037 Exit Requirements: Each floor must have at least two unobstructed exits remote from each other. This requirement was not met as evidenced by K211.
A2054 Smoke Section Walls/Doors: Smoke sections must be separated by one-hour fire-rated walls and doors that are self-closing or held open only by automatic devices. This requirement was not met as evidenced by K321.
A2055 Door Devices: Doors providing separation between floors must have self-closing devices or electromagnetic hold-open devices interconnected with fire alarm systems. This requirement was not met as evidenced by K223.
Report Facts
Facility census: 54
Licensed capacity: 90
Inspection Report
Routine
Census: 54
Deficiencies: 6
Date: Mar 7, 2025
Visit Reason
The inspection was conducted to assess the facility's compliance with providing a safe, clean, comfortable, and homelike environment for residents.
Findings
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.
Deficiencies (6)
Buildup of dust and dirt on the air filter inside the air conditioner unit
Several long dark markings on walls near light switches, doors, beds, and recliners
Areas of exposed sheetrock and peeled paint on walls near recliners, nightstands, and doors
Buildup of dried food and dirt on resident's wheelchair cushion, seat, foot pedals, and sides
Buildup of dirt and grime on the Hoyer lift next to the bed near the window
Missing square vent cover on the ceiling near the sprinkler head in the resident private phone room
Report Facts
Facility census: 54
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Supervisor | Interviewed regarding maintenance issues and repair delays | |
| Administrator | Interviewed regarding awareness of environmental concerns and maintenance log usage |
Inspection Report
Routine
Census: 54
Deficiencies: 9
Date: Mar 7, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident safety, staff background checks, resident assessments, medication administration, nutritional status, pharmaceutical services, and food safety at Cotton Point Living Center.
Findings
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.
Deficiencies (9)
Failed to provide a safe, clean, and comfortable homelike environment with issues such as dust buildup, exposed sheetrock, peeled paint, and unclean resident equipment.
Failed to complete Criminal Background Checks prior to hire and periodic Employee Disqualification List checks for multiple employees.
Failed to electronically transmit quarterly Minimum Data Set (MDS) assessments in a timely manner for multiple residents.
Failed to include admitting diagnosis of PTSD with specific interventions on baseline care plan for a resident.
Failed to obtain and/or follow physician's orders for medications and treatments for several residents, including missed medication administrations and missing oxygen orders.
Failed to implement, monitor, and modify interventions to maintain acceptable nutritional status for residents experiencing severe weight loss.
Failed to ensure staff reconciled narcotics at each shift change for all medication carts, with numerous missed opportunities.
Failed to ensure appropriate diagnoses for the use of psychotropic medications for several residents.
Failed to store and distribute food under sanitary conditions, including missing food and refrigerator temperature logs, unlabeled and undated food items, and unclean kitchen equipment.
Report Facts
Facility census: 54
Missed narcotic reconciliation opportunities: 75
Weight loss percentage: 8.11
Weight loss percentage: 6.9
Weight loss percentage: 11.3
Missed food temperature log opportunities: 42
Missed refrigerator temperature log opportunities: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Employee G | Failed to have quarterly EDL list check | |
| Employee I | No documentation of CBC prior to hire and missing EDL checks | |
| Employee J | Failed to have quarterly EDL list check | |
| Employee K | Failed to have quarterly EDL list check | |
| Employee L | Failed to have quarterly EDL list check | |
| Employee M | Failed to have quarterly or annual EDL list check | |
| Licensed Practical Nurse D | LPN | Described narcotic reconciliation process |
| Licensed Practical Nurse F | LPN | Reported resident did not have hospice order |
| Maintenance Supervisor | Maintenance Supervisor | Acknowledged maintenance issues and communication challenges |
| Administrator | Administrator | Acknowledged environmental concerns, CBC and EDL check requirements, medication order expectations, and narcotic reconciliation procedures |
| Human Resources Staff | HR Staff | Unaware of quarterly EDL check requirements |
| MDS Coordinator | MDS Coordinator | Aware of late MDS assessments |
| Regional Nurse Consultant | Regional Nurse Consultant | Provided expectations on MDS completion and narcotic reconciliation |
| Social Service Director | SSD | Reported resident avoided PTSD questions |
| Director of Nursing | DON | Provided expectations on baseline care plans and oxygen orders |
| Dietary Manager | DM | Discussed weight variance reports and diet order follow-up |
| Registered Dietician | RD | Discussed food temperature monitoring and nutritional assessments |
Inspection Report
Plan of Correction
Census: 54
Deficiencies: 9
Date: Mar 7, 2025
Visit Reason
The inspection was conducted to identify deficiencies and ensure compliance with regulatory requirements at Cotton Point Living Center.
Findings
The facility was found deficient in maintaining a safe, clean, and comfortable homelike environment, developing and implementing abuse/neglect policies, completing criminal background checks, transmitting quarterly Minimum Data Set (MDS) assessments timely, developing baseline care plans, obtaining and following physician orders, maintaining nutrition and hydration status, pharmacy services, and food safety requirements. The facility census was 54 during the inspection.
Deficiencies (9)
F584 Safe/Clean/Comfortable/Homelike Environment: The facility failed to provide a safe, clean, and comfortable homelike environment, evidenced by buildup of dust and dirt, long dark markings, exposed sheetrock, and peeled paint in multiple resident rooms. The facility census was 54.
F607 Develop/Implement Abuse/Neglect Policies: The facility failed to follow policy and procedure to complete criminal background checks for one employee prior to hire and to check the Employee Disqualification List (EDL) quarterly for six other employees. The facility census was 54.
F638 Qrtly Assessment at Least Every 3 Months: The facility failed to electronically transmit quarterly Minimum Data Set (MDS) assessments timely for multiple residents. The facility census was 54.
F655 Baseline Care Plan: The facility failed to include an admitting diagnosis of post traumatic stress disorder (PTSD) with specific interventions on the baseline care plan for one resident. The facility census was 54.
F658 Services Provided Meet Professional Standards: The facility failed to obtain and/or follow physician's orders for three residents. The facility census was 54.
F692 Nutrition/Hydration Status Maintenance: The facility failed to implement, monitor, and modify interventions to maintain acceptable nutritional status for two residents. The facility census was 54.
F755 Pharmacy Services/Procedures/Pharmacist/Records: The facility failed to ensure staff reconciled narcotics at each shift change for three medication carts. The facility census was 54.
F758 Free from Unnec Psychotropic Meds/PRN Use: The facility failed to ensure an appropriate diagnosis for the use of psychotropic medications for three residents. The facility census was 54.
F812 Food Procurement, Store, Prepare, Serve-Sanitary: The facility failed to store and distribute food under sanitary conditions, increasing risk of cross-contamination and food-borne illness. The facility census was 54.
Report Facts
Facility census: 54
Deficiencies cited: 9
Inspection Report
Complaint Investigation
Census: 57
Deficiencies: 1
Date: Feb 4, 2025
Visit Reason
The inspection was conducted due to a complaint regarding misappropriation of a resident's property, specifically the unauthorized use of Resident #1's bank card by a staff member.
Complaint Details
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.
Findings
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.
Deficiencies (1)
Failed to ensure one resident was free of misappropriation of property when Housekeeper A used the resident's bank card for personal use.
Report Facts
Transaction amount: 2544.55
Census: 57
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Housekeeper A | Named as the staff member who misappropriated Resident #1's bank card. | |
| Dietary Aide C | Witness who reported Housekeeper A asked for a ride to the gas station and observed ATM withdrawals. | |
| Housekeeper B | Witness who drove Housekeeper A to the gas station and observed ATM withdrawals. | |
| Administrator | Administrator | Reviewed video footage and reported findings to police. |
| Director of Nursing | Director of Nursing | Notified of the incident by Resident #1's family and assisted with police notification. |
| Police Officer | Interviewed during investigation and stated charges will be pursued against Housekeeper A. |
Inspection Report
Plan of Correction
Census: 57
Deficiencies: 1
Date: Feb 4, 2025
Visit Reason
The visit was conducted to investigate a complaint regarding misappropriation of a resident's property by a staff member.
Complaint Details
Complaint #MO00248600 was investigated and substantiated. The complaint involved alleged misappropriation of a resident's bank card by a housekeeper.
Findings
The facility failed to ensure one resident was free from misappropriation of property when a housekeeper used the resident's bank card for personal use. The facility took disciplinary action against the housekeeper and initiated an investigation involving police and family members.
Deficiencies (1)
F 602: The facility failed to protect a resident from misappropriation of property when a housekeeper used the resident's bank card without consent. The housekeeper was suspended and police charges are pending.
Report Facts
Facility census: 57
Estimated stolen amount: 2544.55
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Housekeeper A | Named as the alleged perpetrator of misappropriation | |
| Dietary Aide C | Witnessed Housekeeper A taking money from ATM | |
| Dietary Aide B | Observed Housekeeper A using the ATM and counted money | |
| Carmine Rivera | LPN LNHA | Signed the report |
Inspection Report
Complaint Investigation
Census: 53
Deficiencies: 5
Date: Dec 18, 2024
Visit Reason
The inspection was conducted to investigate complaints regarding the facility's management of resident funds, including failure to separate resident funds from the facility operating account, lack of timely refunds, absence of written authorization for withdrawals, and failure to provide timely Social Security/Medicaid allowances.
Complaint Details
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.
Findings
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.
Deficiencies (5)
Failed to ensure resident funds were placed in an account separate from the facility operating account and did not provide timely refunds for 12 residents.
Failed to obtain written authorization for money withdrawn for five residents.
Failed to provide Social Security and/or Medicaid monthly allowance in a timely manner for five residents.
Failed to maintain a system to ensure resident trust fund account was managed properly by not reconciling monthly.
Failed to provide a final accounting of resident fund balances within thirty days to the individual or probate jurisdiction administering the resident's estate for discharged and expired residents.
Report Facts
Residents affected: 12
Residents affected: 5
Residents affected: 5
Facility census: 53
Total amount held in operating account: 15270.04
Months without reconciliation: 6
Days delayed refund: 70
Days delayed reporting: 107
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Interim Administrator | Interviewed regarding delays in refunds and authorization for withdrawals | |
| Business Office Manager | Interviewed regarding lack of written authorization for withdrawals and financial management issues | |
| Regional Accountant | Interviewed regarding delays in monthly reconciliations and untimely allowances |
Inspection Report
Annual Inspection
Census: 53
Deficiencies: 10
Date: Dec 18, 2024
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory requirements related to the management and protection of residents' personal funds and other related financial practices at Cotton Point Living Center.
Findings
The facility failed to ensure resident funds were properly segregated from facility operating accounts and did not provide timely refunds or obtain required authorizations for withdrawals. Additionally, the facility did not maintain accurate accounting records, failed to reconcile resident trust fund accounts monthly, and did not provide final accounting of resident funds within required timeframes after discharge or death.
Deficiencies (10)
F567 Protection/Management of Personal Funds: The facility failed to place resident funds in accounts separate from the facility operating account and did not provide timely refunds or obtain written authorization for withdrawals for multiple residents. The facility census was 53.
F568 Accounting and Records of Personal Funds: The facility failed to maintain accurate accounting of resident trust funds by not reconciling accounts monthly and not documenting reconciliations for multiple months. The census was 53.
F569 Notice and Conveyance of Personal Funds: The facility failed to provide final accounting of resident fund balances within 30 days of discharge or death for sampled residents. The census was 53.
A8037 Personal Clothing/Possessions: The facility failed to maintain a record of personal possessions for one resident out of a sample of three. The census was 53.
A8044 Resident Funds Itemized Bill: The facility failed to provide an itemized bill for all goods and services rendered and a complete account of the resident's remaining funds with proper accounting and fiduciary oversight. Refer to F567.
A9002 Resident Fund Use: The facility failed to use resident personal funds exclusively for authorized purposes with written consent. Refer to F567.
A9004 Resident Fund, Monthly Interest: The facility failed to maintain separate accounts and credit interest monthly to resident accounts. Refer to F567.
A9009 Resident Funds Reconciled Monthly: The facility failed to reconcile resident funds monthly and provide statements to residents or their representatives. Refer to F568.
A9010 Discharge Requirement Within 5 Days: The facility failed to provide final accounting of resident funds within five days of discharge for two residents. Refer to F569.
A9011 Death of Resident, Contact DSS: The facility failed to contact the Department of Social Services upon the death of a resident as required. Refer to F569.
Report Facts
Facility census: 53
Refund amounts: 15270.04
Refund days delay: 70
Refund days delay: 107
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jasmine Owens | LPN, WNHA | Signed the inspection report and plan of correction |
Inspection Report
Complaint Investigation
Census: 55
Deficiencies: 1
Date: Aug 27, 2024
Visit Reason
The inspection was conducted due to a complaint alleging misappropriation of a resident's property by a Certified Nurse Aide (CNA).
Complaint Details
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.
Findings
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.
Deficiencies (1)
Failure to protect resident from wrongful use of belongings or money; CNA used resident's bank card for personal use.
Report Facts
Residents present: 55
Amount reimbursed: 191.54
Unauthorized transactions: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA A | Certified Nurse Aide | Admitted to unauthorized use of resident's bank card; terminated and arrested |
| LPN B | Licensed Practical Nurse | Witness during police interview with Resident #1 |
Inspection Report
Complaint Investigation
Census: 55
Deficiencies: 1
Date: Aug 27, 2024
Visit Reason
The inspection was conducted due to a complaint alleging misappropriation of a resident's property by a Certified Nurse Aide (CNA).
Complaint Details
Complaint #MO240597 regarding alleged misappropriation of Resident #1's bank card by CNA A was substantiated based on interviews, record reviews, and police reports.
Findings
The facility failed to ensure one resident was free from misappropriation of property by a CNA who used the resident's bank card for personal use. The CNA was terminated and arrested, and the facility reimbursed the resident for the amount misappropriated.
Deficiencies (1)
F 602: The facility failed to protect a resident from misappropriation of property as a CNA used the resident's bank card without consent for personal purchases. The facility reimbursed the resident and terminated the CNA's employment.
Report Facts
Facility census: 55
Reimbursement amount: 191.54
Unauthorized transactions: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA A | Certified Nurse Aide | Named in misappropriation finding and terminated for misuse of resident's bank card |
| Licensed Practical Nurse B | Licensed Practical Nurse | Witness during police interview regarding the misappropriation incident |
Inspection Report
Routine
Census: 57
Deficiencies: 1
Date: Nov 3, 2023
Visit Reason
The inspection was conducted to assess the facility's compliance with providing adequate care and assistance for activities of daily living (ADLs), specifically focusing on whether residents received a minimum of two showers per week as required.
Findings
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.
Deficiencies (1)
Failure to provide residents with a minimum of two showers per week, resulting in poor hygiene for multiple residents.
Report Facts
Residents affected: 9
Residents affected: 2
Facility census: 57
Missed showers: 5
Missed showers: 7
Missed showers: 9
Missed showers: 1
Missed showers: 8
Missed showers: 8
Missed showers: 8
Missed showers: 2
Missed showers: 4
Missed showers: 8
Missed showers: 7
Missed showers: 2
Missed showers: 9
Missed showers: 8
Missed showers: 1
Missed showers: 1
Missed showers: 5
Missed showers: 7
Missed showers: 8
Missed showers: 1
Missed showers: 3
Missed showers: 4
Missed showers: 8
Missed showers: 1
Missed showers: 6
Missed showers: 6
Missed showers: 9
Missed showers: 1
Missed showers: 9
Missed showers: 7
Missed showers: 5
Missed showers: 1
Missed showers: 8
Missed showers: 4
Missed showers: 3
Missed showers: 1
Missed showers: 4
Missed showers: 3
Missed showers: 7
Missed showers: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Stated expectation for showers to be given at least twice a week and documented | |
| Administrator and Quality Assurance Nurse | Stated expectation for showers to be given at least twice a week and refusals to be documented |
Inspection Report
Routine
Census: 57
Deficiencies: 7
Date: Nov 3, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident dignity, significant change assessments, activities of daily living care, hospice care coordination, fall prevention, medication management, and controlled substances storage and documentation.
Findings
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.
Deficiencies (7)
Failed to ensure resident dignity was maintained during wound care due to lack of privacy curtain.
Failed to complete a significant change Minimum Data Set (MDS) within 14 days of hospice admission.
Failed to provide minimum of two showers per week for nine residents, resulting in poor hygiene and unkempt appearance.
Failed to ensure one hospice resident had a complete coordinated plan of care including documentation of hospice visits, supplies, and signatures.
Failed to monitor and implement adequate fall prevention interventions and 72-hour post-fall monitoring including neuro checks for one resident with multiple falls.
Failed to implement procedures to ensure controlled medications were accurately administered, documented, disposed of, and reconciled for one resident.
Failed to store controlled medications in locked compartments behind two locks as required.
Report Facts
Residents affected: 9
Residents affected: 1
Residents affected: 1
Residents affected: 1
Facility census: 57
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN B | Licensed Practical Nurse | Named in wound care privacy deficiency and medication controlled substance record deficiency |
| LPN C | Licensed Practical Nurse | Named in wound care privacy deficiency |
| CNA D | Certified Nurses Aide | Named in wound care privacy deficiency |
| Director of Nursing | Director of Nursing (DON) | Named in wound care privacy deficiency, significant change MDS deficiency, hospice care coordination, fall prevention, and medication management |
| MDS Coordinator | Named in significant change MDS deficiency | |
| LPN A | Licensed Practical Nurse | Named in hospice care coordination deficiency |
| LPN F | Licensed Practical Nurse | Named in fall prevention and monitoring deficiency |
| Administrator | Administrator | Named in shower care expectations and medication storage deficiency |
| Quality Assurance Nurse | Quality Assurance Nurse | Named in shower care expectations |
Inspection Report
Annual Inspection
Census: 57
Deficiencies: 12
Date: Nov 3, 2023
Visit Reason
The inspection was the annual survey of Cotton Point Living Center to assess compliance with federal and state regulations for nursing homes.
Findings
The facility was found noncompliant with several requirements including resident rights, significant change assessments, activities of daily living care, quality of care, accident prevention, and medication management. Multiple deficiencies were cited related to privacy, showering, care planning, fall prevention, and medication storage and documentation.
Deficiencies (12)
F550 Resident Rights: The facility failed to ensure resident dignity during wound care by not providing privacy curtains for Resident #42.
F637 Comprehensive Assessment After Significant Change: The facility failed to complete a significant change Minimum Data Set (MDS) within 14 days of Resident #37's admission to hospice.
F677 ADL Care Provided for Dependent Residents: The facility failed to provide a minimum of two showers per week for nine residents, including Resident #6, missing multiple shower opportunities from August through November 2023.
F684 Quality of Care: The facility failed to ensure coordinated hospice care plans and proper documentation for Resident #37, and failed to provide adequate supervision and fall prevention interventions for Resident #34.
F689 Quality of Care: The facility failed to re-educate staff on fall assessments and care plans, and failed to monitor and document post-fall neuro checks for Resident #34.
F755 Pharmacy Services: The facility failed to implement accurate medication procedures and failed to properly document medication administration and disposal for Resident #555.
F761 Label/Store Drugs and Biologicals: The facility failed to securely store controlled substances behind two locks and failed to maintain accurate medication records for Residents #37, #19, and #555.
A4055 Safe/Effective Medication System: The facility failed to maintain a safe and effective medication system as evidenced by deficiencies cited under F761.
A4067 Meds Destroyed Within 30 Days: The facility failed to destroy discontinued medications within 30 days as required, referenced under F755.
A4075 Nursing Care per Resident Condition: The facility failed to provide personal attention and nursing care consistent with residents' conditions, referenced under F689.
A4076 Clean, Dry, Odor Free: The facility failed to maintain residents free of offensive odors, referenced under F677.
A8030 Dignity/Privacy: The facility failed to ensure resident dignity and privacy, referenced under F550.
Report Facts
Facility census: 57
Number of residents missing minimum showers: 9
Number of sampled residents: 15
Number of residents outside sample: 2
Medication doses not reconciled: 1
Inspection Report
Life Safety
Census: 57
Deficiencies: 5
Date: Nov 3, 2023
Visit Reason
The inspection was conducted to assess compliance with life safety code requirements, including emergency preparedness, means of egress illumination, and fire drill procedures.
Findings
The facility failed to maintain complete emergency preparedness policies for sheltering in place, lacked proper illumination of means of egress, and did not perform required quarterly fire drills on each shift. These deficiencies had the potential to affect residents, staff, and visitors.
Deficiencies (5)
E022 Policies/Procedures for Sheltering in Place. The facility failed to have complete policies and procedures available for staff to review in case sheltering in place was needed. The emergency disaster plan forms for disaster kits, food/water storage, and emergency tools were blank.
K281 Illumination of Means of Egress. The facility failed to maintain illumination of means of egress in accordance with NFPA 101, including inadequate lighting on the designated emergency exit sidewalk.
K712 Fire Drills. The facility failed to perform fire drills on each shift quarterly and at varying times and conditions, with only six of twelve drills held in the last month.
A2037 Exit Requirements. The facility did not meet the requirement for at least two unobstructed exits remote from each other on each floor, with one exit leading directly outside at grade level.
A2063 Fire Drill Records. The facility failed to keep complete records of all fire drills including time, date, personnel, length, and narrative of special problems.
Report Facts
Facility census: 57
Fire drills held: 6
Fire drills required: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Donna Cannon | Administrator | Interviewed regarding emergency preparedness and signed the report |
| Maintenance Supervisor | Interviewed about lighting installation and fire drill scheduling | |
| Director of Maintenance | Interviewed about scheduling fire drills |
Inspection Report
Complaint Investigation
Census: 54
Deficiencies: 1
Date: Apr 6, 2023
Visit Reason
The inspection was conducted due to a complaint regarding the failure to provide a functional call light system throughout the facility, affecting multiple residents on the 100 hall.
Complaint Details
Complaint #MO214262 regarding non-functional call light system affecting resident safety and ability to summon assistance.
Findings
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.
Deficiencies (1)
Failure to provide a functional call light system in each resident's bathroom and bathing area.
Report Facts
Residents affected: 13
Facility census: 54
Date of work order: Apr 4, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Interviewed regarding expectations for functioning call lights and maintenance follow-up. | |
| Maintenance Director | Interviewed about awareness of call light system issues and maintenance actions. |
Inspection Report
Complaint Investigation
Census: 54
Deficiencies: 2
Date: Apr 6, 2023
Visit Reason
The inspection was conducted as a complaint investigation related to the facility's resident call system functionality.
Complaint Details
Complaint #MO214262 was investigated. The complaint concerned the malfunctioning resident call light system. The investigation substantiated the complaint as the call lights were found non-functional in multiple resident rooms.
Findings
The facility failed to provide a functional call light system throughout the building, affecting 13 residents. Observations and interviews confirmed multiple residents' call lights were non-functional, and maintenance records showed unresolved issues.
Deficiencies (2)
F919 Resident Call System CFR(s): 483.90(g)(1)(2) The facility failed to provide a functional call light system at each resident's bedside and toilet/bathing facilities, affecting 13 residents. Maintenance records showed unresolved call light issues and no documentation of repairs.
A3026 19 CSR 30-85.032(27) Call System Requirements The facility's call system did not meet regulatory requirements for audible signals in the attendant's work area and for each resident bed, toilet room, and bathroom. This was evidenced by the F919 deficiency.
Report Facts
Residents affected: 13
Facility census: 54
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Lydia Upkey | Administrator | Signed the inspection and plan of correction documents |
Inspection Report
Plan of Correction
Census: 51
Deficiencies: 14
Date: Oct 8, 2021
Visit Reason
The document is a Plan of Correction submitted in response to a survey conducted on 10/08/2021 at Cotton Point Living Center. It addresses deficiencies identified during the inspection.
Findings
The facility failed to notify residents of survey results, ensure accuracy of advance directives, notify the State Long-Term Care Ombudsman of emergency transfers, and maintain complete and accurate care plans. Additional deficiencies include failure to follow physician orders, document medication administration properly, and provide education on vaccinations.
Deficiencies (14)
F577 The facility failed to notify residents of the availability and location of the most recent survey results in an accessible location. This affected multiple residents and visitors.
F578 The facility failed to ensure the accuracy of advance directives regarding residents' resuscitation status and failed to notify the State Long-Term Care Ombudsman of emergency transfers for two residents.
F623 The facility failed to notify the State Long-Term Care Ombudsman of emergency transfers to the hospital for two residents and failed to provide proper transfer/discharge notices.
F624 The facility failed to document preparation and orientation for transfer for one resident, including missing documentation of transfer preparation.
F656 The facility failed to develop and implement comprehensive, person-centered care plans that address residents' specific needs, affecting two residents.
F658 The facility failed to follow physician orders for medication administration, including discontinuing medications and documenting code status, affecting multiple residents.
F758 The facility failed to ensure PRN psychotropic medications were not ordered for more than 14 days without proper physician documentation and rationale.
F883 The facility failed to provide education and documentation regarding influenza and pneumococcal vaccinations for residents, including failure to document refusals and immunization status.
A4053 No medication, treatment, or diet shall be given without a written order from a person lawfully authorized to prescribe. This regulation was not met.
A4074 Each resident shall receive personal attention and nursing care consistent with current acceptable nursing practice. This regulation was not met.
A4085 Residents shall be cared for by using acceptable infection control procedures to prevent the spread of infection. This regulation was not met.
A8001 The facility shall retain and make available for public inspection a list of names, addresses, and occupations of individuals with property interest in the facility and copies of official notifications of violations and responses. This regulation was not met.
A8010 Prior to or upon admission and annually, residents or their representatives shall be informed of facility policies regarding emergency and life-sustaining care. This regulation was not met.
A8018 In emergency discharge situations, the facility shall submit written notice of discharge and advise residents of their rights. This regulation was not met.
Report Facts
Facility census: 51
Sampled residents: 13
Deficiency completion dates: Completion dates for corrective actions are listed as 11/15/21 and 11/22/21.
Inspection Report
Life Safety
Census: 51
Deficiencies: 2
Date: Oct 8, 2021
Visit Reason
The inspection was conducted to assess compliance with the 2012 Existing Edition of the Life Safety Code of the National Fire Protection Association (NFPA) and related fire safety regulations.
Findings
The facility failed to maintain required exit illumination and sprinkler systems, potentially affecting all residents and staff. Observations showed lack of battery backup for emergency lighting and sprinkler heads covered in dust and debris, with missing sprinkler coverage at the service hall entrance overhang.
Deficiencies (2)
K281: The facility failed to maintain required exit illumination with emergency battery backup, potentially affecting all residents and staff. Observation showed exterior illumination lighting lacked battery backup.
K353: The facility failed to maintain required sprinkler systems, potentially affecting all residents and staff. Observations showed sprinkler heads covered in dust and debris and missing sprinkler coverage at the service hall entrance overhang.
Report Facts
Facility census: 51
Inspection Report
Routine
Census: 51
Deficiencies: 9
Date: Oct 8, 2021
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident rights, care planning, medication administration, transfer and discharge procedures, and vaccination policies.
Findings
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.
Deficiencies (9)
Failed to notify residents of the availability and location of the most recent survey results in an accessible location.
Failed to ensure accuracy of advance directives regarding resuscitation status for two residents.
Failed to notify the Office of the State Long-Term Care Ombudsman of emergency hospital transfers for two residents.
Failed to document preparation and orientation for hospital transfer for one resident.
Failed to ensure residents had complete, accurate, and individualized care plans addressing specific needs, including code status documentation.
Failed to follow physician's orders for three residents, including failure to discontinue or reduce medications as recommended by the consultant pharmacist.
Failed to document and monitor fluid intake accurately for a resident on a 2-liter fluid restriction, including failure to document fluids served and consumed with meals and medications.
Failed to ensure consultant pharmacist made recommendations and attending physician documented rationale for continued use of PRN psychotropic medication beyond 14 days for one resident.
Failed to provide information and education to a resident or representative regarding pneumococcal vaccines and failed to document vaccination status or consent/refusal.
Report Facts
Residents affected: 2
Residents affected: 2
Residents affected: 2
Residents affected: 1
Residents affected: 2
Residents affected: 3
Residents affected: 1
Residents affected: 1
Residents affected: 1
Facility census: 51
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse A | Licensed Practical Nurse | Provided information regarding resident code status and fluid restriction documentation |
| Administrator | Provided multiple interviews regarding facility expectations for survey results accessibility, code status documentation, transfer notification, medication administration, fluid restriction, and vaccination policies | |
| Consultant Pharmacist | Provided recommendations for medication changes and discussed facility follow-up on recommendations | |
| Dietary Manager | Provided information regarding dietary fluid restriction procedures and documentation | |
| Registered Dietitian | Provided expectations for dietary staff regarding fluid restriction documentation | |
| Resident #8's and #13's physician | Discussed expectations for medication changes and follow-up |
Inspection Report
Routine
Deficiencies: 0
Date: Sep 14, 2021
Visit Reason
A COVID-19 Focused Emergency Preparedness survey and a COVID-19 Focused Infection Control Survey were conducted to assess compliance with relevant federal regulations and CDC recommended practices.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness and with CMS and CDC recommended practices for COVID-19 infection control.
Inspection Report
Complaint Investigation
Census: 59
Deficiencies: 2
Date: Apr 16, 2021
Visit Reason
The inspection was conducted due to a complaint investigation regarding a resident elopement incident and protective oversight failures at Cotton Point Living Center.
Complaint Details
Complaint #MO184066 was substantiated. The violation was determined to be at an imminent danger class I level at the time of the complaint investigation.
Findings
The facility failed to provide adequate supervision and protective oversight to prevent a resident from leaving the premises unsupervised, resulting in the resident being missing for over eight hours and found in a hazardous area. The investigation revealed deficiencies in staff monitoring, communication, and implementation of elopement precautions.
Deficiencies (2)
F689: The facility failed to ensure the resident environment remained free of accident hazards and did not provide adequate supervision to prevent a resident from leaving unsupervised, resulting in the resident being missing for over eight hours.
A4073: The facility failed to provide twenty-four hour protective oversight and supervision for residents on voluntary leave, resulting in an imminent danger to resident safety.
Report Facts
Facility census: 59
Inspection Report
Routine
Deficiencies: 0
Date: Apr 1, 2021
Visit Reason
A COVID-19 Focused Emergency Preparedness survey and a COVID-19 Focused Infection Control Survey were conducted to assess compliance with relevant regulations and CDC recommended practices.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness and with CMS and CDC recommended practices for COVID-19 infection control. No deficiencies were cited as a result of the onsite complaint investigations.
Inspection Report
Routine
Deficiencies: 0
Date: Sep 1, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness survey and a COVID-19 Focused Infection Control Survey were conducted to assess compliance with relevant regulations and CDC recommended practices.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness and with CMS and CDC recommended practices for COVID-19 infection control.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Aug 19, 2020
Visit Reason
A complaint investigation was conducted in conjunction with a COVID-19 Focused Infection Control Survey on 08/19/2020.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness and in substantial compliance with CMS and CDC recommended practices for COVID-19 infection control.
Inspection Report
Routine
Deficiencies: 0
Date: May 28, 2020
Visit Reason
A COVID-19 focused infection control and emergency preparedness survey was conducted to assess compliance with CMS and CDC recommended practices and 42 CFR 483.73 regulations.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices for COVID-19 infection control and with 42 CFR 483.73 related to emergency preparedness.
Inspection Report
Plan of Correction
Census: 42
Deficiencies: 11
Date: Aug 29, 2019
Visit Reason
The inspection was conducted to assess compliance with federal and state regulations regarding resident assessments, care planning, medication administration, infection control, and food safety at Cotton Point Living Center.
Findings
The facility was found deficient in accurately coding resident assessments, developing individualized care plans, following physician orders for medications, maintaining medication error rates below 5%, ensuring infection control protocols for employees, and storing food safely under sanitary conditions. Multiple residents' records showed errors or omissions in assessments, care plans, and medication administration.
Deficiencies (11)
F641 Accuracy of Assessments. The facility failed to accurately code the Minimum Data Set (MDS) for five residents, including errors in marking antipsychotic use, smoking status, side rail use, and discharge status. The facility census was 42.
F656 Develop/Implement Comprehensive Care Plan. The facility failed to implement care plans with specific interventions tailored to individual needs for one resident with depression. The facility census was 42.
F658 Services Provided Meet Professional Standards. The facility failed to follow physician orders for medications for three residents, including missing orders and medication administration errors. The facility census was 42.
F756 Drug Regimen Review, Report Irregular, Act On. The facility failed to ensure PRN orders for psychotropic drugs were limited to 14 days and reviewed by a physician for one resident. The facility census was 42.
F758 Free from Unnec Psychotropic Meds/PRN Use. The facility failed to ensure psychotropic drug orders were properly reviewed and psychotropic medication usage was monitored for one resident. The facility census was 42.
F759 Free of Medication Error Rts 5 Prcnt or More. The facility failed to maintain a medication error rate below 5%, with 3 errors in 26 opportunities (11.54%) affecting two residents. The facility census was 42.
F812 Food Procurement, Store/Prepare/Serve-Sanitary. The facility failed to store food under sanitary conditions, with opened and undated food items in the kitchen freezer, increasing risk of contamination. The facility census was 42.
A4029 Communicable Disease-Employees. The facility failed to follow infection control protocols for tuberculosis screening of new employees, with incomplete employee records and delayed screenings. The facility census was 42.
A4054 Safe/Effective Medication System. The facility failed to maintain a safe and effective medication system as evidenced by deficiencies noted in F758 and F759.
A4060 Drug Regimen Review-Monthly. The facility failed to ensure monthly pharmacist review of drug regimens and timely reporting of irregularities as evidenced by deficiencies noted in F756.
A4074 Nursing Care per Res Condition. The facility failed to provide personal attention and nursing care consistent with current acceptable nursing practice as evidenced by deficiencies noted in F658.
Report Facts
Facility census: 42
Medication error opportunities: 26
Medication errors: 3
Medication error rate: 11.54
Residents sampled: 12
Inspection Report
Life Safety
Census: 42
Deficiencies: 6
Date: Aug 29, 2019
Visit Reason
The inspection was conducted to assess compliance with life safety code requirements, including emergency preparedness, fire safety, and electrical equipment safety at Cotton Point Living Center.
Findings
The facility failed to maintain adequate emergency supplies, exterior exit illumination, sprinkler coverage in the medication room, conduct fire drills at unexpected times, prohibit space heaters in non-designated areas, and restrict use of extension cords and power strips. These deficiencies potentially affected all residents and staff.
Deficiencies (6)
E015: The facility failed to maintain adequate emergency supplies including food, water, and alternate energy sources. This affected all residents and staff.
K281: The facility failed to maintain adequate exterior exit illumination as required by NFPA 101. No battery powered illumination was provided for the entire facility.
K351: The facility failed to maintain adequate sprinkler coverage in the medication room. The room measured 56 square feet and lacked a required sprinkler head.
K712: The facility failed to conduct fire drills at unexpected times and under varied conditions at least quarterly on each shift. Fire drills were missed in the second shift for the first quarter of 2019.
K781: The facility failed to prohibit space heaters in non-designated areas. Space heaters were found in the therapy room and nurse's station.
K920: The facility failed to prohibit use of extension cords and power strips that do not meet standards. Multiple power strips and extension cords were in use in resident care areas.
Report Facts
Facility census: 42
Staff count: 20
Total people on site: 62
Water supply packs: 3
Medication room size: 56
Inspection Report
Complaint Investigation
Census: 45
Deficiencies: 2
Date: Jun 25, 2019
Visit Reason
The inspection was conducted as a complaint investigation related to concerns about the facility's compliance with professional standards of care, specifically regarding wound dressing changes and adherence to physician orders for residents.
Complaint Details
Complaint #MO00157260 was investigated. The complaint was substantiated based on findings of missed dressing changes and failure to follow physician orders.
Findings
The facility failed to follow physician orders for wound dressing changes for two residents, missing numerous dressing change opportunities and lacking proper documentation. Interviews revealed staff turnover and communication issues contributing to the deficiencies.
Deficiencies (2)
F658 Services Provided Meet Professional Standards CFR(s): 483.21(b)(3)(i). The facility failed to follow physician orders for wound dressing changes for two residents, missing multiple dressing change opportunities and lacking documentation.
A4074 19 CSR 30-85.042(67) Nursing Care per Resident Condition. Each resident shall receive personal attention and nursing care consistent with current nursing practice. This regulation was not met as evidenced by Class II deficiency related to F658.
Report Facts
Facility census: 45
Missed dressing change opportunities for Resident #1: 29
Missed dressing change opportunities for Resident #1: 9
Missed dressing change opportunities for Resident #2: 55
Missed dressing change opportunities for Resident #2: 34
Missed dressing change opportunities for Resident #2: 38
Inspection Report
Complaint Investigation
Census: 40
Deficiencies: 4
Date: Jun 17, 2019
Visit Reason
The inspection was conducted as a complaint investigation related to resident handling and nurse aide hiring practices at Cotton Point Living Center.
Complaint Details
Complaint MO #156440 triggered the investigation. The complaint involved unsafe resident transfer practices and inadequate nurse aide hiring and training procedures. The complaint was substantiated based on observations and record reviews.
Findings
The facility failed to ensure safe transfer techniques for residents, resulting in a skin tear for one resident. Additionally, the facility did not ensure nurse aides met competency and registry verification requirements before providing care.
Deficiencies (4)
F689 Free of Accident Hazards/Supervision/Devices: The facility staff failed to provide a safe transfer technique during a resident's wheelchair to bed transfer, resulting in a skin tear on the resident's left forearm.
F728 Facility Hiring and Use of Nurse Aide: The facility failed to ensure one nurse aide had completed required training and competency evaluation prior to working with residents.
F729 Nurse Aide Registry Verification, Retraining: The facility failed to verify nurse aide registry status before allowing the nurse aide to provide care, despite the aide working 5.5 hours without verification.
A4074 Nursing Care per Resident Condition: Each resident shall receive personal attention and nursing care consistent with current acceptable nursing practice. This regulation was not met as evidenced by F689.
Report Facts
Facility census: 40
Nurse aide hours worked: 5.5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN F | Licensed Practical Nurse | Documented resident transfer incident and refused to assist with transfer |
| Administrator | Involved in resident transfer resulting in skin tear and admitted lack of training and policy adherence | |
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding nurse aide hiring and training practices |
| NA G | Nurse Aide | Worked without completing required training and registry verification |
Inspection Report
Annual Inspection
Census: 13
Deficiencies: 4
Date: Oct 25, 2018
Visit Reason
The inspection was conducted as an annual survey to assess compliance with federal and state regulations for Cotton Point Living Center.
Findings
The facility was found deficient in maintaining resident privacy, developing comprehensive baseline care plans, posting nurse staffing information, and infection prevention and control practices. The facility failed to provide privacy curtains for semi-private rooms, did not ensure baseline care plans addressed specific resident needs, failed to post nurse staffing data in a prominent place, and did not maintain adequate infection control practices related to blood glucose monitoring.
Deficiencies (4)
F583 Privacy and Confidentiality of Records: The facility failed to provide privacy curtains for residents in semi-private rooms, compromising resident privacy during personal care.
F655 Baseline Care Plan: The facility failed to ensure baseline care plans included specific interventions tailored to residents' needs for four residents.
F732 Nurse Staffing Information: The facility failed to post nurse staffing data in a prominent, accessible place at the beginning of each shift.
F880 Infection Prevention & Control: The facility failed to maintain infection control practices to prevent transmission of infection related to blood glucose monitoring for three residents.
Report Facts
Facility census: 13
Residents affected: 4
Residents affected: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Julie Harris | Administrator | Signed the inspection report and plan of correction |
| Licensed Practical Nurse B | Licensed Practical Nurse | Observed and interviewed regarding blood glucose monitoring and nurse staffing |
| Director of Nursing | Director of Nursing | Interviewed regarding privacy curtains, baseline care plans, nurse staffing, and infection control |
Inspection Report
Life Safety
Census: 13
Deficiencies: 6
Date: Oct 25, 2018
Visit Reason
The inspection was conducted to assess compliance with the 2012 Existing Edition of the Life Safety Code of the National Fire Protection Association (NFPA) and related reference documents.
Findings
The facility failed to maintain ceilings free of penetrations to resist smoke passage, provide a smooth and obstruction-free exit discharge path, maintain emergency egress lighting, maintain kitchen range hood to NFPA code, maintain the fire sprinkler system, and maintain smoke barrier walls free from penetrations. These deficiencies potentially affected all residents, staff, and occupants in the event of a fire.
Deficiencies (6)
K161: The facility failed to maintain ceilings free of penetrations to resist the passage of smoke, as evidenced by ducts and access panels not properly sealed. The facility census was 13.
K271: The facility failed to provide a smooth, hard surface path to the public way from exit discharge areas, including a five inch depression and travel over grass beyond concrete pad. The facility census was 13.
K281: The facility failed to maintain emergency egress lighting for the building, with no emergency exit illumination to the public way. The facility census was 13.
K324: The facility failed to maintain the kitchen range hood to NFPA code, with no monthly inspections of the wet chemical suppression system since June 4, 2018. The facility census was 13.
K353: The facility failed to maintain the fire sprinkler system, with seven loaded sprinkler heads under the front canopy containing dust and debris. The facility census was 13.
K372: The facility failed to maintain smoke barrier walls free from penetrations, with holes in the smoke barrier wall by the laundry room and on 100 hall allowing air ducts and cables to pass without fire block. The facility census was 13.
Report Facts
Facility census: 13
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