Inspection Reports for
New Madrid Living Center
1050 DAWSON RD, NEW MADRID, MO, 63869-1116
Back to Facility ProfileDeficiencies (last 7 years)
Deficiencies (over 7 years)
8.1 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
47% worse than Missouri average
Missouri average: 5.5 deficiencies/yearDeficiencies per year
16
12
8
4
0
Occupancy
Latest occupancy rate
48% occupied
Based on a September 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Occupancy rate 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
Life Safety
Census: 59
Deficiencies: 6
Date: Oct 10, 2024
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 hazardous areas free of penetrations, failed to maintain sprinkler heads free of dust and debris, and failed to restrict combustible decorations. These deficiencies potentially affected all residents and staff.
Deficiencies (6)
K321 Hazardous areas are not maintained free of penetrations, including unsealed holes in the main mechanical room. This potentially affected all residents and staff.
K353 The sprinkler system is not maintained properly; sprinkler heads were found loaded with dust and debris, potentially affecting all residents and staff.
K753 Combustible decorations are used in the facility, including a candle with a wick in the Social Services office, which is prohibited and could cause harm to residents.
A2008 Hazardous areas are not separated by required fire-resistant construction or automatic sprinkler system as per regulation, referencing K321.
A2009 Unnecessary combustible materials are stored in the facility, presenting a fire hazard, referencing K753.
A2034 The sprinkler system is not inspected, maintained, and tested in accordance with regulatory requirements, referencing K353.
Report Facts
Facility census: 59
Inspection Report
Plan of Correction
Census: 59
Deficiencies: 4
Date: Oct 10, 2024
Visit Reason
The inspection was conducted to assess compliance with federal and state regulations regarding accuracy of assessments and infection prevention and control at New Madrid Living Center.
Findings
The facility failed to accurately reflect residents' status in Minimum Data Set (MDS) assessments for two residents and did not maintain proper infection control practices for two residents, potentially affecting all residents. Deficiencies were noted in documentation, use of personal protective equipment, and adherence to CDC guidelines for infection prevention.
Deficiencies (4)
F641 Accuracy of Assessments: The facility failed to accurately code the Minimum Data Set (MDS) for two residents, with diagnoses and documentation not properly reflected in assessments. The facility census was 59.
F880 Infection Prevention & Control: The facility failed to establish and maintain an infection prevention and control program, including proper use of personal protective equipment and adherence to CDC guidelines, affecting residents with indwelling medical devices and those on COVID-19 isolation precautions.
A4086 Infection Control/Communicable Disease: The facility did not use acceptable infection control procedures to prevent the spread of infection and failed to report communicable diseases as required by Missouri regulations.
A4108 Clinical Records - assessment/interventions: The facility did not ensure clinical records contained sufficient information to reflect initial and ongoing assessments and interventions by each discipline involved in resident care.
Report Facts
Facility census: 59
Sampled residents for MDS accuracy: 15
Residents with inaccurate MDS coding: 2
Residents with infection control deficiencies: 2
Days for reporting communicable disease: 7
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
Plan of Correction
Census: 59
Deficiencies: 2
Date: Apr 8, 2024
Visit Reason
The inspection was conducted to investigate and document deficiencies related to resident safety and care, specifically regarding accident hazards and supervision during resident transfers.
Findings
The facility failed to ensure the safety of a resident during a transfer, resulting in a fractured tibia/fibula. Staff did not follow the care plan or use proper transfer techniques, and the facility lacked a policy on proper transfers.
Deficiencies (2)
F689 Free of Accident Hazards/Supervision/Devices: The facility failed to ensure the resident environment was free of accident hazards and did not provide adequate supervision or assistance devices during transfers, resulting in a resident sustaining a fractured tibia/fibula.
A4075 Nursing Care per Resident Condition: Each resident shall receive personal attention and nursing care consistent with their condition and current nursing practice. This regulation was not met as evidenced by the deficiency in F689.
Report Facts
Facility census: 59
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
Plan of Correction
Deficiencies: 3
Date: Sep 6, 2023
Visit Reason
This document is a statement of deficiencies and plan of correction for New Madrid Living Center following a survey completed on 09/06/2023.
Findings
The facility was found deficient in nursing care per resident condition, physician notification of changes in condition, and notification of responsible parties after significant changes. Deficiencies were classified as Class II and Class III.
Deficiencies (3)
19 CSR 30-85.042(66) Nursing Care per Resident Condition was not met. Each resident did not receive personal attention and nursing care consistent with their condition and current nursing practice.
19 CSR 30-85.042(78) Physician Notification-Change in Condition was not met. Facility staff failed to notify the resident's physician in accordance with emergency treatment policies after significant changes.
19 CSR 30-85.042(79) Notification of Responsible Party-Change in Condition was not met. Facility staff did not immediately notify the designated responsible party after significant changes in the resident's condition.
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 |
Inspection Report
Plan of Correction
Census: 55
Deficiencies: 3
Date: Jun 29, 2023
Visit Reason
The inspection was conducted to assess compliance with federal regulations regarding resident assessments and medication management at New Madrid Living Center.
Findings
The facility failed to accurately document Minimum Data Set (MDS) assessments for one resident and did not have a policy for MDS assessments. Additionally, expired medications were found in medication storage areas, and the facility lacked a policy regarding expired medications.
Deficiencies (3)
F641 Accuracy of Assessments: The facility failed to document a complete and accurate Minimum Data Set (MDS) assessment for one resident and lacked a policy for MDS assessments.
F761 Label/Store Drugs and Biologicals: The facility failed to ensure medications were not expired in medication storage rooms and carts, and lacked a policy regarding expired medications.
A4067 19 CSR 30-85.042(58) Meds Destroyed Within 30 Days: The facility did not destroy outdated, contaminated, or deteriorated medications and non-unit dose medications of deceased residents within 30 days.
Report Facts
Facility census: 55
Sampled residents: 14
Deficiencies cited: 3
Inspection Report
Life Safety
Census: 55
Capacity: 112
Deficiencies: 2
Date: Jun 29, 2023
Visit Reason
The inspection was an Emergency Preparedness survey focusing on compliance with the 2012 Existing Edition of the Life Safety Code and fire drill requirements.
Findings
The facility failed to meet the requirements for conducting fire drills under varying conditions on each shift quarterly. The fire drills were not conducted as required, potentially delaying response procedures in the event of a fire.
Deficiencies (2)
42 CFR 483.90(a): The facility does not meet the applicable provisions of the 2012 Existing Edition of the Life Safety Code related to fire drills. The facility failed to conduct fire drills under varying conditions on each shift quarterly, which may delay response procedures.
19 CSR 30-85.022(33)(D): The facility did not conduct the required minimum of twelve fire drills annually with at least one every three months on each shift. At least four drills must be unannounced and include a simulated resident evacuation involving emergency services.
Report Facts
Facility census: 55
Total capacity: 112
Fire drills required annually: 12
Fire drills required quarterly on each shift: 1
Unannounced fire drills required annually: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Interviewed regarding fire drill procedures and plans for improvement | |
| Administrator | Signed the report and plan of correction |
Inspection Report
Plan of Correction
Census: 56
Deficiencies: 4
Date: Jun 11, 2021
Visit Reason
The inspection was conducted to assess compliance with federal regulations regarding safe, clean, and homelike environment and accurate resident assessments at New Madrid Living Center.
Findings
The facility failed to provide a safe, clean, and homelike environment as evidenced by damaged walls and ceiling tiles. The facility also failed to timely and accurately transmit Minimum Data Set (MDS) assessments for residents.
Deficiencies (4)
F584 Safe Environment. The facility failed to maintain a safe, clean, and homelike environment, including damaged walls and ceiling tiles in multiple resident rooms.
F640 Encoding/Transmitting Resident Assessments. The facility failed to electronically transmit admission MDS data for one resident in a timely manner as required.
F641 Accuracy of Assessments. The facility failed to accurately code the Minimum Data Set for one resident, incorrectly coding aspirin as an anticoagulant medication.
A3038 Furniture/Equip, Provide Comfort & Safety. The facility failed to maintain furniture and equipment in good condition, referencing the F584 deficiency.
Report Facts
Facility census: 56
Sampled residents for MDS review: 14
Residents with MDS issues: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Mentioned in interview regarding aspirin coding on MDS |
| Administrator | Administrator | Interviewed regarding maintenance concerns and MDS submission |
| MDS Coordinator | MDS Coordinator | Interviewed regarding MDS submission and assessment issues |
Inspection Report
Life Safety
Census: 56
Deficiencies: 8
Date: Jun 11, 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 reference documents.
Findings
The facility failed to meet several life safety requirements including maintaining hazardous areas free of penetrations, prohibiting combustible decorations, maintaining proper clearance around electrical panels, and ensuring safe use of power cords and extension cords. These deficiencies potentially affected all residents and staff.
Deficiencies (8)
K321 Hazardous Areas - Enclosure: The facility failed to maintain high hazard areas free of penetrations, including two penetrations above a sprinkler pipe and missing sheetrock around an access door frame.
K753 Combustible Decorations: The facility failed to maintain the facility free of combustible decorations, including a previously burned candle on a shelf and a candle on filing cabinets.
K911 Electrical Systems - Other: The facility failed to maintain proper clearance around electrical panels, with push carts stored against panels in the janitor closet.
K920 Electrical Equipment - Power Cords and Extension Cords: The facility failed to maintain the facility free of temporary wiring, including use of a power strip in a patient care vicinity.
A2008 Hazardous Areas: Hazardous areas were not separated by at least one-hour fire-resistant construction as required.
A2009 Combustible Materials, Unnecessary: The storage of unnecessary combustible materials was prohibited but not met.
A3030 Electrical Wiring & Equipment Maintained: Electrical wiring and equipment were not installed and maintained in accordance with NFPA 70, 1999 edition.
A3037 Extension Cords/Duplex Receptacles: Extension cords were not used according to safety standards, including multiple appliances on one extension cord and cords placed under rugs or through doorways.
Report Facts
Facility census: 56
Inspection Report
Routine
Deficiencies: 0
Date: Oct 14, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control Survey was conducted to assess compliance with related 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 infection control practices for COVID-19.
Inspection Report
Routine
Deficiencies: 0
Date: Sep 28, 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 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 infection control practices for COVID-19.
Inspection Report
Routine
Deficiencies: 0
Date: Aug 12, 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
Routine
Deficiencies: 0
Date: May 29, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey and a COVID-19 Focused Emergency Preparedness survey were conducted to assess compliance with CMS and CDC guidelines and federal 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
Annual Inspection
Census: 80
Deficiencies: 7
Date: Jun 20, 2019
Visit Reason
The inspection was conducted as an annual survey to assess compliance with federal regulations for nursing facilities, including review of resident care, assessments, and staff training.
Findings
The facility was found deficient in multiple areas including preparation for safe transfer or discharge, comprehensive assessment after significant change, timely transmission of MDS data, accuracy of assessments, development of comprehensive care plans, and nurse aide performance reviews. The facility failed to meet regulatory requirements in these areas as evidenced by record reviews and interviews.
Deficiencies (7)
F624 Preparation for Safe/Orderly Transfer/Discharge: The facility failed to document preparation and orientation for transfer to the hospital for two residents. The facility's census was 80.
F637 Comprehensive Assessment After Significant Change: The facility failed to complete a significant change assessment for two residents within 14 days of the change. The facility's census was 80.
F640 Encoding/Transmitting Resident Assessments: The facility failed to electronically transmit annual and quarterly MDS assessments timely for five residents. The facility's census was 80.
F641 Accuracy of Assessments: The facility failed to document a complete and accurate Minimum Data Set assessment for one resident. The facility's census was 80.
F656 Develop/Implement Comprehensive Care Plan: The facility failed to implement an individualized comprehensive care plan for one resident. The facility's census was 80.
F730 Nurse Aide Perform Review-12 hr/yr In-Service: The facility failed to complete performance reviews and provide in-service education for nurse aides annually. The facility's census was 80.
A4025 In-service-Annually, Nursing/Restorative: The facility failed to conduct at least annual in-service education for nursing personnel including training in restorative nursing. Refer to F730.
Report Facts
Facility census: 80
Residents sampled: 18
Residents with deficiencies: 5
Inspection Report
Life Safety
Census: 80
Deficiencies: 6
Date: Jun 20, 2019
Visit Reason
The inspection was a life safety code survey to assess compliance with the 2012 Existing Edition of the Life Safety Code of the National Fire Protection Association (NFPA) and related regulations.
Findings
The facility failed to maintain unobstructed means of egress, failed to maintain appropriate testing on exit illumination lights, failed to maintain adequate exit signage, and failed to maintain required electrical outlet inspections. These deficiencies potentially affected all residents and staff.
Deficiencies (6)
K211 Means of Egress - The facility failed to maintain unobstructed means of egress, with chains hooked across doorways in half of all occupied resident rooms.
K281 Illumination of Means of Egress - The facility failed to maintain appropriate testing on exit illumination lights and could not provide documentation of the 90-minute emergency lighting tests.
K293 Exit Signage - The facility failed to maintain adequate exit signage, including no exit signage leading from the garden patio area off the dining room.
K912 Electrical Systems - Receptacles - The facility failed to maintain required electrical outlet inspections and could not provide the required inspection documentation.
A2046 Corridor Requirements - The facility failed to maintain corridors free of obstruction, with resident room doors swinging into the corridor.
A2047 Exit Sign Requirements - The facility failed to place signs bearing the word EXIT in plain, legible block letters at each required exit except at doors directly from rooms to exit corridors or passageways.
Report Facts
Facility census: 80
Deficiencies cited: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jim Lee | Administrator | Signed the report and plan of correction |
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Apr 27, 2018
Visit Reason
The inspection was conducted as an annual recertification survey for the New Madrid Living Center.
Findings
No deficiencies were cited as a result of this annual recertification survey. No state licensure deficiencies were found during the inspection.
Document
Deficiencies: 0
Visit Reason
This document is a plan of correction submitted in response to a life safety code inspection conducted at the facility.
Findings
The plan addresses identified life safety code deficiencies and outlines corrective actions to ensure compliance.
Viewing
Loading inspection reports...
