Inspection Reports for
McDonald County Living Center
1000 PATTERSON ST, ANDERSON, MO, 64831-7327
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
3.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
31% better than Missouri average
Missouri average: 5.5 deficiencies/yearDeficiencies per year
12
9
6
3
0
Occupancy
Latest occupancy rate
58% occupied
Based on a July 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Complaint Investigation
Census: 56
Deficiencies: 2
Date: Jul 30, 2025
Visit Reason
The inspection was conducted following complaints regarding medication administration errors and pharmaceutical service deficiencies at McDonald County Living Center.
Complaint Details
Complaint #1778398 related to failure to administer medications as ordered due to unavailable drugs and lack of follow-up. Complaint #1778395 related to medication error involving insulin administration to the wrong resident.
Findings
The facility failed to provide pharmaceutical services ensuring timely administration of medications for one resident due to unavailable drugs and lack of follow-up with the pharmacy and physician. Additionally, a medication error occurred when insulin prescribed for one resident was mistakenly administered to another resident without diabetes, resulting in hospital admission. The facility corrected the non-compliance and provided staff education.
Deficiencies (2)
Failure to provide pharmaceutical services ensuring administration of all drugs as ordered due to unavailable medications and lack of follow-up with pharmacy and physician for Resident #3.
Medication error where insulin prescribed for Resident #2 was administered to Resident #1 who did not have orders for insulin, resulting in hospital admission.
Report Facts
Medication doses missed: 18
Insulin units administered in error: 12
Facility census: 56
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN A | Licensed Practical Nurse | Administered insulin medication in error to the wrong resident and reported the error. |
| CMT B | Certified Medication Technician | Provided interview regarding medication administration policies and error prevention. |
| LPN C | Licensed Practical Nurse | Provided interview about medication administration and error prevention. |
| LPN D | Licensed Practical Nurse | Provided interview about medication administration and error prevention. |
| Director of Nursing | Director of Nursing (DON) | Conducted investigation and staff in-service following medication error; provided multiple interviews. |
| Administrator | Facility Administrator | Provided interview regarding expectations for medication administration and response to errors. |
| Quality Assurance Nurse | Quality Assurance Nurse | Provided interview regarding medication administration policies and error reporting. |
Inspection Report
Routine
Deficiencies: 3
Date: Dec 12, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory standards related to pressure ulcer care, food safety, and hospice service coordination at McDonald County Living Center.
Findings
The facility was found deficient in providing consistent pressure ulcer prevention care, ensuring food items were properly air-dried before storage, and maintaining effective communication and documentation regarding hospice services for a resident.
Deficiencies (3)
Failure to provide pressure ulcer prevention care by not ensuring staff awareness and consistent implementation of protective heel boots for a resident at risk.
Failure to ensure food was protected from contamination by not allowing bowls and pans to air dry before storage.
Failure to have a system ensuring consistent communication and collaboration of care between facility and hospice staff, with lack of hospice documentation for a resident receiving hospice services.
Report Facts
Residents affected: 1
Residents affected: 54
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant 1 | CNA | Mentioned in relation to failure to implement heel boots for pressure ulcer prevention |
| Certified Nursing Assistant 2 | CNA | Mentioned in relation to placing heel boots on resident |
| Licensed Practical Nurse 2 | LPN | Confirmed resident had order for heel boots but resident kicked them off |
| Director of Nursing | DON | Provided information about pressure ulcer prevention and care plan deficiencies |
| Medical Records Staff | MR Staff | Discussed lack of hospice documentation and communication |
| Administrator | Administrator | Discussed hospice communication and documentation issues |
Inspection Report
Complaint Investigation
Census: 58
Deficiencies: 1
Date: Aug 8, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to ensure residents were appropriately assessed before allowing self-administration of medications at bedside, which resulted in one resident becoming unresponsive after self-administering medications.
Complaint Details
The complaint investigation found that the resident self-administered two medications without a physician's order to keep medications at bedside, became unresponsive, and required emergency intervention with Narcan and hospital transfer. The resident had signed against medical advice (AMA) and was given medications back by staff prematurely. The facility was found noncompliant but corrected the issue with staff education.
Findings
The facility failed to properly assess and document the safety of allowing a resident to self-administer medications at bedside. One resident self-administered two medications without a physician's order to keep medications at bedside and was found unresponsive, requiring Narcan administration and hospital transfer. Staff returned the resident's home medications prior to the resident leaving the facility against medical advice, contrary to policy. The facility provided in-service education to staff and corrected the noncompliance promptly.
Deficiencies (1)
Failed to ensure residents were appropriately assessed to have medication at bedside prior to providing bedside medications, resulting in a resident self-administering medications without proper orders and becoming unresponsive.
Report Facts
Residents present: 58
Date of incident: Jun 24, 2024
Medication doses: 2
Medication doses administered: 1
Medication doses not administered: 1
Time of Narcan administration: 815
Time resident signed AMA: 330
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Notified physician and Administrator, completed in-service education, involved in resident assessment and notification during incident |
| Administrator | Administrator | Notified of resident incident and medication issues, interviewed regarding facility medication policies |
| Licensed Practical Nurse B | Licensed Practical Nurse (LPN) | Interviewed about medication handling and policies regarding resident medications |
| Licensed Practical Nurse C | Licensed Practical Nurse (LPN) | Interviewed about medication handling, removal of medications left in resident rooms, and notification procedures |
| Social Services Designee | Social Services Designee (SSD) | Communicated with hospital and provided information about resident AMA status |
Inspection Report
Routine
Census: 69
Deficiencies: 9
Date: Apr 28, 2023
Visit Reason
Routine inspection of McDonald County Living Center to assess compliance with regulatory requirements including resident dignity, privacy, medication administration, bed hold policy, staffing, infection control, food safety, and facility cleanliness.
Findings
The facility was found deficient in multiple areas including failure to ensure resident dignity with catheter bag placement, lack of privacy during toileting, failure to provide written bed hold policy upon hospital transfers, improper posting of nurse staffing hours, medication administration errors related to insulin timing, expired medications on medication carts, wet stacked dishes risking bacterial growth, inadequate hand hygiene during care, and unclean kitchen vents and air conditioning units.
Deficiencies (9)
Failure to ensure dignity of resident by not placing catheter collection bag inside a dignity bag.
Failure to provide privacy during toileting for a resident.
Failure to notify resident or representative in writing of bed hold policy during hospital transfers.
Failure to post daily nurse staffing information in a prominent, accessible location including total hours worked.
Failure to ensure residents received meal intake within 30 minutes of insulin administration as recommended.
Failure to maintain accurate accountability and removal of expired or unusable medications and topical ointments.
Failure to keep food contact surfaces dry before stacking, risking bacterial growth.
Failure to ensure proper hand hygiene during blood glucose monitoring, insulin administration, incontinent care, and toileting.
Failure to keep kitchen area clean with dust/debris and cobwebs on air conditioning units, vents, and metal shelving.
Report Facts
Residents affected: 1
Residents affected: 1
Residents affected: 4
Residents affected: 69
Residents affected: 2
Expired medications: 5
Wet dishes observed: 101
Residents affected: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN H | Licensed Practical Nurse | Named in medication administration and hand hygiene deficiencies |
| LPN I | Licensed Practical Nurse | Named in medication administration and hand hygiene deficiencies |
| RN K | Registered Nurse | Named in hand hygiene deficiency |
| CNA M | Certified Nurse Aide | Named in incontinent care hand hygiene deficiency |
| CNA O | Certified Nurse Aide | Named in toileting privacy and hand hygiene deficiency |
| Dietary Manager | Named in kitchen cleanliness deficiency | |
| Administrator | Interviewed regarding multiple deficiencies including staffing, medication, hand hygiene, and kitchen cleanliness | |
| Director of Nursing | DON | Interviewed regarding multiple deficiencies including staffing, medication, hand hygiene |
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Nov 15, 2019
Visit Reason
Annual survey inspection of McDonald County Living Center to assess compliance with health and safety regulations.
Findings
No health deficiencies were found during the inspection.
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