Inspection Reports for
New Madrid Living Center
1050 DAWSON RD, NEW MADRID, MO, 63869-1116
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
4 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
27% better than Missouri average
Missouri average: 5.5 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
54 residents
Based on a September 2025 inspection.
Occupancy over time
Inspection Report
Census: 54
Deficiencies: 3
Date: Sep 18, 2025
Visit Reason
The inspection was conducted to evaluate compliance with residents' rights regarding code status documentation, notification of transfers and bed hold policies, and the development of baseline care plans upon admission.
Findings
The facility failed to ensure accurate and consistent documentation of residents' code status for two residents, failed to notify residents and their representatives in writing about hospital transfers and bed hold policies for four residents, and failed to develop and implement baseline care plans with specific interventions within 48 hours of admission for one resident. The level of harm was minimal with few residents affected.
Deficiencies (3)
Failure to ensure a code status was accurately and consistently documented throughout the medical record for two residents.
Failure to notify the resident and the resident's representative in writing of a transfer or discharge to a hospital, including reasons for transfer and bed hold policy, for four residents.
Failure to develop and implement a baseline care plan with specific interventions within 48 hours of admission for one resident.
Report Facts
Residents affected: 2
Residents affected: 4
Residents affected: 1
Facility census: 54
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN) A | Interviewed regarding code status documentation and transfer/bed hold forms | |
| Licensed Practical Nurse (LPN) C | Interviewed regarding code status documentation | |
| Certified Nursing Assistant (CNA) D | Interviewed regarding code status location | |
| Social Services Designee (SSD) | Interviewed regarding code status review and bed hold policy | |
| Registered Nurse (RN) B | Interviewed regarding code status review and baseline care plan responsibility | |
| Administrator | Interviewed regarding expectations for code status documentation and transfer notifications | |
| Assistant Director of Nursing (ADON) | Interviewed regarding code status documentation and bed hold policy | |
| Director of Nursing (DON) | Interviewed regarding baseline care plan expectations |
Inspection Report
Routine
Census: 59
Deficiencies: 2
Date: Oct 10, 2024
Visit Reason
The inspection was conducted to assess compliance with federal regulations regarding accurate resident assessments and infection prevention and control practices at New Madrid Living Center.
Findings
The facility failed to accurately code the Minimum Data Set (MDS) for two residents, resulting in inaccurate documentation of diagnoses and medication use. Additionally, the facility failed to maintain proper infection control practices for two residents, including failure to use appropriate personal protective equipment (PPE) and isolation precautions, potentially affecting all residents.
Deficiencies (2)
Failure to accurately code the Minimum Data Set (MDS) for two residents, resulting in undocumented diagnoses and medication use.
Failure to maintain proper infection control practices for two residents, including failure to use gloves and gowns when required and improper isolation precautions for a resident with Covid-19.
Report Facts
Residents affected: 2
Residents affected: 2
Facility census: 59
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse C | Licensed Practical Nurse | Failed to put on a gown prior to entering Resident #10's room to administer medication and feeding |
| Certified Nurse Assistant A | Certified Nurse Assistant | Entered Resident #30's room without gown or gloves and failed to close door or change N95 mask |
| Certified Nurse Assistant B | Certified Nurse Assistant | Entered Resident #30's room with gown and mask but failed to put on gloves and left door open |
| MDS Coordinator | Completed the MDS assessments; name not provided | |
| Director of Nursing | Interviewed regarding MDS assessments and infection control expectations; name not provided | |
| Administrator | Interviewed regarding MDS assessments and infection control expectations; name not provided |
Inspection Report
Complaint Investigation
Census: 59
Deficiencies: 2
Date: Apr 8, 2024
Visit Reason
The inspection was conducted due to a complaint investigation following an incident where a resident sustained a fractured right tibia/fibula during a transfer when staff failed to follow the care plan and use proper technique.
Complaint Details
The investigation was triggered by a complaint related to an injury sustained by Resident #1 during transfer on 04/02/2024. The complaint was substantiated as staff failed to use the mechanical lift and did not report the incident immediately. Resident #1 sustained a fracture confirmed by X-ray.
Findings
The facility failed to ensure resident safety during transfers, resulting in a fracture of Resident #1's right tibia/fibula. Staff did not use the required mechanical lift, and the resident's injury was not immediately reported. The facility lacked a policy regarding proper transfers.
Deficiencies (2)
Failure to ensure safety during resident transfer resulting in fractured right tibia/fibula due to staff not following care plan and not using mechanical lift.
Facility did not provide a policy regarding proper transfers.
Report Facts
Residents present: 59
Date of injury: Apr 2, 2024
Date of X-ray report: Apr 2, 2024
Date of family hospital transfer request: Apr 3, 2024
Date resident admitted to hospital: Apr 4, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA B | Certified Nurse Aide | Transferred Resident #1 without mechanical lift and did not report injury |
| CNA C | Certified Nurse Aide | Reported resident's leg swelling and bruising to charge nurse |
| CNA D | Certified Nurse Aide | Observed resident mobility and swelling, reported injury |
| LPN A | Licensed Practical Nurse | Charge nurse who assessed injury and notified physician |
| Administrator | Conducted investigation into resident injury |
Inspection Report
Complaint Investigation
Census: 60
Deficiencies: 3
Date: Sep 6, 2023
Visit Reason
The inspection was conducted due to a complaint regarding the facility's failure to notify a resident's guardian about a critical lab value and failure to provide timely care and notification related to the resident's condition.
Complaint Details
Complaint #MO223597 regarding failure to notify guardian of critical lab results and failure to provide timely care and notification.
Findings
The facility failed to notify the guardian of a resident's critical lab value and delayed notifying the physician, resulting in the resident's hospital admission for severe hypernatremia. Additionally, the facility failed to assess risks, discuss benefits, and obtain informed consent for bed rail use for the resident.
Deficiencies (3)
Failed to notify a resident's guardian after a change in condition with a critical lab value.
Failed to provide necessary care and timely physician notification for critical lab values, resulting in hospital admission.
Failed to assess risk, review risks and benefits, and obtain informed consent for bed rail use prior to installation.
Report Facts
Critical lab sodium value: 165
Hospital sodium lab value: 166
Facility census: 60
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse A | Licensed Practical Nurse (LPN) | Interviewed regarding lab reporting and bed rail use |
| Licensed Practical Nurse B | Licensed Practical Nurse (LPN) | Notified nurse practitioner's office by fax of critical lab value |
| Nurse Practitioner | Nurse Practitioner (NP) | Interviewed regarding lab notification procedures and on-call responsibilities |
| Registered Nurse G | Registered Nurse (RN) | Interviewed regarding bed rail assessment and consent |
| Administrator | Interviewed regarding notification procedures and bed rail consent |
Inspection Report
Census: 55
Deficiencies: 2
Date: Jun 29, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to accurate resident assessments and proper medication storage, including checking for expired medications.
Findings
The facility failed to document a complete and accurate Minimum Data Set (MDS) for one resident and failed to provide a policy for MDS assessment. Additionally, expired medications were found in medication storage rooms and carts, with no policy provided regarding expired medications.
Deficiencies (2)
Failed to document a complete and accurate Minimum Data Set (MDS) for one resident, including missing documentation of diuretic use, insulin use, and dementia diagnosis.
Failed to ensure medications were not expired in medication storage rooms and medication carts, including expired ondansetron, meclizine, miconazole cream, and Gerilanta.
Report Facts
Residents affected: 1
Residents affected: 1
Residents potentially affected: 1
Facility census: 55
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Interviewed regarding expectations for accurate MDS and medication storage | |
| Administrator | Interviewed regarding expectations for accurate MDS and medication storage | |
| MDS Coordinator | Interviewed regarding expectations for accurate MDS | |
| Assistant Director of Nursing | Interviewed regarding expectations for medication storage |
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