Inspection Reports for
McDonald County Living Center
1000 PATTERSON ST, ANDERSON, MO, 64831-7327
Back to Facility ProfileDeficiencies (last 7 years)
Deficiencies (over 7 years)
5.1 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
7% better than Missouri average
Missouri average: 5.5 deficiencies/year
Deficiencies per year
20
15
10
5
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
Complaint Investigation
Census: 54
Deficiencies: 3
Date: Dec 12, 2024
Visit Reason
A Recertification and Complaint Survey was conducted by Healthcare Management Solutions, LLC on behalf of the Missouri Department of Health and Senior Services. The survey was triggered by a complaint intake MO00243680 and included a review of compliance with federal regulations.
Complaint Details
Complaint intake MO00243680 was investigated and no deficient practice was found related to the complaint itself, but deficiencies were identified in related areas of care.
Findings
The facility was found not to be in substantial compliance with 42 CFR 483 subpart B. Deficiencies were identified related to pressure ulcer prevention, food safety, and hospice services coordination and documentation.
Deficiencies (3)
F686: The facility failed to provide pressure ulcer prevention care per standards of practice when staff did not ensure all were aware of and implemented a new order for protective heel boots for a sampled resident.
F812: The facility failed to ensure food was protected from contamination when kitchen staff did not air-dry bowls and pans prior to storage, risking foodborne illness for all 54 residents.
F849: The facility failed to meet hospice service requirements by lacking coordination, communication, and documentation of hospice care for one resident.
Report Facts
Survey Census: 54
Sample Size: 26
Supplemental Residents: 0
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
Life Safety
Census: 54
Capacity: 96
Deficiencies: 5
Date: Dec 11, 2024
Visit Reason
An Emergency Preparedness Survey and a Life Safety Code Survey were conducted to assess compliance with fire safety and emergency preparedness regulations.
Findings
The facility was found compliant with emergency preparedness requirements but noncompliant with several Life Safety Code requirements, including fire barrier integrity, delayed egress door locking, cooking facility fire door closure, sprinkler system coverage, and electrical outlet testing.
Deficiencies (5)
K161: Facility failed to maintain the one-hour fire rating in the attic fire wall due to unsealed penetrations where sprinkler pipes and cables passed through. This affected all 54 residents.
K222: Facility failed to ensure all egress doors had 15-second delayed egress locking that released properly after fire alarm activation. One door in the dining room did not open when pushed.
K324: Facility failed to ensure fire rated doors in the kitchen closed completely and latched, allowing potential fire spread. The kitchen fire door did not close or latch properly.
K351: Facility failed to ensure full sprinkler coverage in all areas, including a janitor's closet and laundry room where sprinklers were missing or improperly installed.
K914: Facility failed to conduct required annual electrical outlet testing. No documented evidence of testing was found and the Maintenance Director confirmed testing was not completed.
Report Facts
Occupied beds: 54
Licensed beds: 96
Delayed egress door release time: 15
Penetration sizes: 6" x 9", ½" x 2", and 8" x 13" penetrations in attic fire wall
Sprinkler offset: 1.5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Interviewed and confirmed fire wall penetrations, door issues, sprinkler coverage, and electrical testing deficiencies |
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
Plan of Correction
Census: 58
Deficiencies: 1
Date: Aug 8, 2024
Visit Reason
This document is a Plan of Correction submitted by McDonald County Living Center following a deficiency cited during a survey completed on 08/08/2024.
Findings
The facility failed to ensure residents were appropriately assessed for self-administration of medications at bedside, resulting in a resident self-administering two medications and becoming unresponsive. The deficiency was corrected after notification and staff education.
Deficiencies (1)
F 554: The facility failed to ensure residents were appropriately assessed for self-administration of medications at bedside, resulting in a resident self-administering two medications and becoming unresponsive.
Report Facts
Facility census: 58
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
Life Safety
Census: 69
Capacity: 96
Deficiencies: 8
Date: Apr 25, 2023
Visit Reason
The inspection was a Life Safety Code survey conducted to assess compliance with fire safety and building construction standards at McDonald County Living Center.
Findings
The facility failed to maintain the integrity of building construction, ensure proper operation of egress doors with delayed-egress locking, maintain sprinkler system coverage and maintenance, and ensure electrical safety compliance. Multiple deficiencies were identified that potentially affected residents and staff.
Deficiencies (8)
K161: The facility failed to maintain the one-hour fire rating of ceilings due to unsealed penetrations in the attic affecting 17 residents. The building is wood construction with one-hour fire-rated ceilings but lacked a policy on penetrations.
K222: The facility failed to ensure five egress doors with 15-second delayed-egress locking released properly during fire alarm tests, potentially affecting 31 residents and others. No policy was provided for maintenance of egress doors.
K223: Hazardous areas had self-closing doors that were not functional or missing, including storage rooms and kitchen entrance, affecting 77 residents. No policy was provided regarding self-closing doors in hazardous areas.
K353: The sprinkler system was not maintained properly; one sprinkler head was obstructed by a truss in the attic, and sprinkler heads were dirty or covered with debris, affecting 17 residents. No policy was provided for sprinkler system maintenance.
K372: The facility failed to maintain the smoke resistive properties of smoke barrier walls due to unsealed metal conduits with cables passing through, affecting 69 residents. No policy was provided for maintenance of smoke barrier walls.
K912: Electrical outlets near water sources lacked ground fault interrupters (GFI) on a hydrocollator and ice machine, affecting 69 residents. No policy was provided for electrical receptacle maintenance.
K918: The facility failed to complete a required four-hour load test for the emergency generator in the past three years, affecting 69 residents. No policy was provided for generator maintenance and testing.
K920: The facility allowed improper use of power strips, outlet extenders, and surge protectors in patient care areas, affecting 69 residents. No policy was provided regarding power tap usage.
Report Facts
Facility capacity: 96
Resident census: 69
Potentially affected residents: 17
Potentially affected residents: 31
Potentially affected residents: 77
Potentially affected residents: 69
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Aug 2, 2022
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control survey was conducted as a complaint investigation.
Complaint Details
This was a complaint investigation related to COVID-19 preparedness and infection control. No deficiencies were cited.
Findings
The facility was found to be in compliance with 42 CFR 483.73 and CDC recommended practices for COVID-19. No deficiencies were cited during this complaint investigation.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Aug 18, 2021
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control Survey was conducted as a complaint investigation.
Complaint Details
No deficiencies were cited on this complaint investigation.
Findings
The facility was found to be in compliance with 42 CFR 483.73 and CDC recommended practices for COVID-19. No deficiencies were cited during this complaint investigation.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Dec 17, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control survey was conducted to assess compliance with CMS and CDC recommended practices related to COVID-19.
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
Routine
Deficiencies: 0
Date: Nov 19, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control survey was conducted to assess the facility's compliance with related regulations and CDC recommended practices.
Findings
The facility was found to be in compliance with 42 CFR 483.73 and CMS and CDC recommended practices for COVID-19 preparedness and infection control.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Jul 16, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control Survey was conducted to assess compliance with CMS and CDC recommended practices related to COVID-19.
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
Abbreviated Survey
Deficiencies: 0
Date: May 27, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control Survey was conducted to assess compliance with CMS and CDC recommended practices related to COVID-19.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness and with CMS and CDC recommended infection control practices for COVID-19.
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.
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Nov 15, 2019
Visit Reason
The inspection was conducted as an annual recertification and licensure inspection of McDonald County Living Center.
Findings
No deficiencies were cited as a result of the annual recertification survey or the state licensure inspection.
Inspection Report
Plan of Correction
Census: 77
Deficiencies: 2
Date: Jan 18, 2019
Visit Reason
The document is a plan of correction related to deficiencies found during a survey completed on January 18, 2019, concerning the resident call system at McDonald County Living Center.
Findings
The facility failed to provide a call light activation switch in two public restrooms near the business office, which is required for residents to call staff assistance. The maintenance supervisor was unaware that the public restrooms needed a call light switch.
Deficiencies (2)
F919 Resident Call System: The facility failed to provide a call light activation switch in two toilet rooms near the business office. Both rooms did not have a call light activation switch as observed on 1/15/19.
A3026 Call System Requirements: The facility did not meet the requirement for a call system consisting of an electrical intercommunication system or equivalent audible system in the attendant's work area. Refer to F919 for details.
Report Facts
Facility census: 77
Inspection Report
Life Safety
Census: 77
Capacity: 96
Deficiencies: 2
Date: Jan 18, 2019
Visit Reason
The inspection was conducted to assess compliance with the Life Safety Code (LSC) of the National Fire Protection Association (NFPA) and related regulations, focusing on egress door locking arrangements and fire safety systems.
Findings
The facility failed to meet the applicable provisions of the Life Safety Code regarding egress doors, specifically delayed egress locking hardware on an exit door in the Special Needs Unit. The door did not release within 15 seconds when pressure was applied, posing a potential safety risk to residents, visitors, and staff.
Deficiencies (2)
K222 Egress Doors: The facility failed to ensure one exit door equipped with delayed egress locking hardware released within 15 seconds when the panic bar was pushed. This posed a potential risk to all residents, visitors, and staff using the Special Needs Unit exit.
A2055 Door Devices: The facility did not meet the requirement for attached self-closing devices on doors providing separation between floors, with electromagnetic hold-open devices not properly interconnected with smoke alarms or fire systems.
Report Facts
Facility capacity: 96
Census: 77
Date of alleged compliance: 02/27/2019 as stated in Plan of Correction
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dawn Webb | Administrator | Signed the inspection report and Plan of Correction |
Document
Deficiencies: 0
Visit Reason
The document does not provide any information regarding the reason for visit or inspection.
Findings
No findings or content are available in the document.
Viewing
Loading inspection reports...
