Below average — CMS composite of the measures below.
A standard survey is most likely before around August 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Cedargate Health Care Center during CMS and state inspections, most recent first.
Missed Scheduled Showers for Two Residents: Two residents did not receive the minimum of two scheduled showers per week. One resident with COPD, schizophrenia, anxiety, major depressive disorder, and heart failure was dependent on staff for bathing and personal hygiene, had missed multiple showers, and was observed with unkempt hair. Another resident with COPD and Crohn's disease was dependent on staff for bathing and also missed multiple showers. Staff and leadership stated residents should receive showers twice weekly, with missed showers attributed to time management issues and short staffing.
The facility failed to store and distribute food under sanitary conditions, using non-pasteurized eggs for undercooked preparations and maintaining unclean kitchen equipment and storage areas. Eleven residents were served undercooked eggs made from non-pasteurized shell eggs, and various kitchen surfaces were found to be unclean, with black and white substances observed on the ice machine and sticky films on kitchen equipment. Dented cans and a sticky film on the floor were also noted.
The facility failed to maintain water temperatures between 105°F to 120°F in resident room sinks and a community shower, with recorded temperatures ranging from 129.2°F to 134.5°F. This deficiency persisted despite the installation of a new water heater, posing a burn risk to all 49 residents.
The facility failed to ensure resident privacy during care by leaving two residents exposed. One resident with multiple diagnoses, including diabetes and heart failure, was left exposed to the backyard view, while another resident with severe cognitive impairment and other conditions was exposed to the courtyard view. Staff did not close the blinds during incontinent care.
The facility failed to maintain a safe, clean, and comfortable environment, with observations of water leaks, fecal material, and unsanitary conditions in multiple areas. The maintenance log showed no completed work orders since December 2023, and the Maintenance Supervisor had only been in the position for three weeks. The Administrator confirmed that staff should complete work orders for maintenance to address.
The facility failed to provide written notification to residents and/or their representatives for hospital transfers. Two residents were transferred multiple times without documented written notifications, despite the facility's process requiring such notifications.
The facility failed to provide written notification of the bed-hold policy to residents and/or their representatives at the time of transfer for two residents. Interviews with staff revealed inconsistencies in the process of ensuring that the notifications were sent out as required by the facility's policy.
The facility failed to implement comprehensive, person-centered care plans with specific interventions for three residents diagnosed with Alzheimer's disease, anxiety disorder, major depressive disorder, and dementia. Interviews confirmed that these conditions should be included in care plans with both pharmacological and non-pharmacological interventions.
The facility failed to ensure a complete hospice care plan for a resident and did not adhere to the repositioning protocol for another resident, leading to extended periods without repositioning despite the care plan requirements.
The facility failed to ensure proper placement and handling of Foley catheter tubing and drainage bags for two residents. One resident's catheter tubing was touched by a nurse's shoe, and another resident's catheter drainage bag and tubing were observed touching the floor multiple times and not covered with a dignity bag, contrary to facility policy.
The facility failed to ensure proper storage of nasal cannulas and did not follow oxygen orders for two residents. One resident's nasal cannula was found on the floor and improperly placed back in use, while another resident's oxygen concentrator was set incorrectly, and the nasal cannula was improperly stored or not in use.
The facility failed to identify, assess, and provide supportive interventions for a resident diagnosed with PTSD. Despite the resident's PTSD being documented in their medical records, the care plan did not address PTSD or include necessary interventions. Interviews with staff confirmed that PTSD should have been included in the care plan.
The facility failed to maintain a medication error rate of less than five percent, resulting in an error rate of 6.25%. Two residents were affected by the administration of expired insulin and incorrect insulin dosages, indicating a failure to adhere to the facility's policies on insulin administration and medication storage.
The facility failed to discard opened, multi-use vials of insulin after the 28-day expiration period, as per manufacturer's instructions. Observations revealed multiple expired vials on the CMT medication cart, and interviews with staff indicated a misunderstanding of the expiration guidelines.
The facility failed to maintain proper infection control practices during incontinent care, catheter care, and wound care for multiple residents. Staff did not perform hand hygiene between glove changes, use gloves and gowns as required, or clean contaminated surfaces. These actions were inconsistent with the facility's infection control policies.
The facility failed to document education provided to residents or their representatives regarding the benefits, side effects, or warnings of the influenza and pneumococcal vaccines. This deficiency was identified for four residents, with no documentation found in their medical records despite receiving the vaccines.
Missed Scheduled Showers for Two Residents
Penalty
Summary
The facility failed to provide ADL assistance for bathing when two residents did not receive the minimum of two showers per week. The facility policy titled, Resident Showers, stated residents would be provided showers as requested or according to the facility schedule protocols and based on resident safety. The facility Resident Shower List showed both residents were scheduled for showers two times weekly on Wednesdays and Saturdays, but the shower records showed missed showers for each resident during the review period. Resident #1 had diagnoses including COPD, schizophrenia, anxiety disorder, major depressive disorder, and heart failure. The quarterly MDS showed the resident was cognitively intact but dependent on staff for dressing, personal hygiene, and bathing. The care plan identified dependence on staff for showers, need for two staff for showers, and total assistance with personal hygiene, but did not address shower frequency or schedule. Shower sheets showed four missed showers out of 19 opportunities, and the resident was observed in a wheelchair with unkempt hair while appropriately dressed. Resident #2 had diagnoses of COPD and Crohn's disease, was cognitively intact, and was dependent on staff for bathing and dressing with supervision or touching assistance for personal hygiene. The care plan did not address the amount of assistance, frequency, or shower schedule. Shower sheets showed six missed showers out of 19 opportunities, and the resident stated he/she often did not receive showers twice a week. Staff interviews confirmed residents should have showers twice weekly, with missed showers attributed to time management issues and short staffing.
Food Storage and Sanitation Deficiencies
Penalty
Summary
The facility failed to store and distribute food under sanitary conditions, as observed during a survey. Non-pasteurized shell eggs were used to prepare undercooked eggs for eleven residents, contrary to the facility's policy that only pasteurized eggs should be used for such preparations. The walk-in refrigerator contained a partially full case of non-pasteurized eggs, and the interior surface of the door had a brown substance. The Dietary Manager confirmed that pasteurized eggs had not been ordered recently, and the Administrator acknowledged that the eggs should have been pasteurized if served undercooked. Additionally, the ice machine and various kitchen surfaces were found to be unclean, with black and white substances observed on the ice machine and sticky films on kitchen equipment. Dented cans were also found in the dry food storage room, and the floor had a sticky film and separated tiles with a black substance underneath. The Maintenance Director admitted that the ice machine had not been checked for cleanliness since he started three weeks ago. The Administrator confirmed that the conditions observed were not in line with the facility's standards for cleanliness and food safety. The facility did not provide a kitchen policy, and the existing policy on food preparation and service was outdated, last revised in 2014. The deficiencies observed had the potential to affect all residents in the facility, which had a census of 49 at the time of the survey.
Failure to Maintain Safe Water Temperatures
Penalty
Summary
The facility failed to ensure the environment remained free of accident hazards by not maintaining water temperatures between 105 degrees Fahrenheit (F) to 120 degrees F in five occupied resident room sinks and a community shower. This failure was observed during a survey where water temperatures in various rooms were recorded between 129.2 degrees F and 134.5 degrees F, significantly exceeding the safe range. The facility's policy required water heaters to be set to no more than 120 degrees F, and maintenance staff were responsible for checking and recording water temperatures. However, the facility's Weekly Temperature Check Logs showed inconsistent and often unsafe temperature ranges, indicating a lack of proper monitoring and adjustment of water temperatures over several months. Additionally, the facility had been experiencing water temperature issues for months, with a new water heater installed recently, but the problem persisted with temperatures now being too high instead of too low as previously reported by the Administrator and Maintenance Supervisor. During the survey, it was observed that the digital hot water heater had a reading of 131 degrees F and an operational set point of 135 degrees F, with an error message indicating a heating circuit issue. The Maintenance Supervisor admitted to turning up the hot water heater to compensate for having only one heater instead of two for a period of time. Despite the installation of a new water heater, the facility failed to adjust the temperature settings appropriately, resulting in dangerously high water temperatures that posed a risk of burns to residents. The facility census was 49, indicating that all residents were potentially affected by this deficiency.
Failure to Ensure Resident Privacy During Care
Penalty
Summary
The facility failed to ensure staff treated residents with dignity and respect by leaving two residents exposed during care. Resident #6, who has diagnoses including diabetes mellitus, atrial fibrillation, chronic diastolic heart failure, anxiety disorder, major depressive disorder, and insomnia, was observed lying in bed while Nurse Aide E and Certified Nurse Aide F performed incontinent care without closing the blinds on the window. This exposed the resident to the view of the backyard from the window. The resident's quarterly Minimum Data Set (MDS) indicated that the resident had intact cognition, was always incontinent of bladder and bowel, had impairments to one side of upper limbs and both lower limbs, and was dependent for toileting, hygiene, and mobility. Similarly, Resident #19, who has diagnoses including dementia, contracture of the hand muscle, anxiety disorder, convulsions, Parkinsonism, aphasia, and a history of transient cerebral ischemic attack, was observed sitting in a wheelchair while Nurse Aide E and Certified Nurse Aide F performed incontinent care without closing the blinds on the window. The resident was transferred via hoyer lift to the bed closest to the window, exposing the resident to the view of the courtyard. The resident's quarterly MDS indicated severe cognitive impairment, always incontinent of bladder and bowel, impairments to both upper and lower limbs, and dependency for toileting, hygiene, and mobility. Interviews with the Director of Nursing, Nurse Aide E, and the Administrator confirmed that window blinds should always be closed prior to any resident care being provided.
Failure to Maintain a Safe and Clean Environment
Penalty
Summary
The facility failed to provide a safe, clean, and comfortable homelike environment, as evidenced by multiple observations of unsanitary and hazardous conditions. Over several days, surveyors observed water dripping from an HVAC ceiling vent near a resident's room and the west wing nursing station, with a yellow caution cone placed beneath it. Additionally, the east wing men's handicap shower room was found with piles of fecal material, a toilet with separated caulk seal and black substance, and ceramic tiles with black substance. Similar unsanitary conditions were noted in the east wing women's shower room and a resident's room, where fecal material was smeared on the toilet seat. Residents reported ongoing issues with fecal material in the bathrooms. Further observations revealed multiple brown areas on ceiling tiles in various locations, including the memory care hall, dining room, and medical record storage area, indicating potential water damage or mold growth. The men's and women's shower rooms on the 100 Hall also had caulking with black substance and missing sections of caulk, contributing to the unsanitary environment. The facility's maintenance log showed no completed work orders since December 2023, and the Maintenance Supervisor confirmed receiving work orders related to plumbing and electrical issues but had only been in the position for three weeks. The Administrator stated that staff should complete work orders for the Maintenance Supervisor to address. The lack of a policy regarding the environment and the failure to address these maintenance issues resulted in a deficient practice that had the potential to affect all 49 residents in the facility.
Failure to Provide Written Notification of Transfers
Penalty
Summary
The facility failed to notify the resident and/or the resident's representative in writing of a facility-initiated transfer when two residents were transferred to the hospital. Resident #11 was transferred to the hospital for medical evaluation on three separate occasions and readmitted each time, but there was no documentation of written notifications provided to the resident or the resident's representative for any of these transfers. Similarly, Resident #45 was transferred to the hospital for medical evaluation and readmitted, but there was no documentation of written notification provided for this transfer either. Interviews with various staff members, including a Registered Nurse (RN), the Administrator, the Social Services Designee (SSD), the Director of Nursing (DON), and the Business Office Manager (BOM), revealed that the facility had a process in place for handling transfer/discharge notifications. However, the process was not consistently followed, as evidenced by the lack of documentation in the residents' medical records. The RN mentioned that the transfer packet included a Notice of Transfer or Discharge form, which was supposed to be mailed to the resident's responsible party, but this step was not documented. The Administrator and other staff confirmed that the forms were supposed to be filed and mailed, but there was no evidence that this was done for the transfers in question.
Failure to Provide Written Notification of Bed-Hold Policy
Penalty
Summary
The facility failed to provide written notification of the bed-hold policy to residents and/or their representatives at the time of transfer for two residents. Resident #11 was transferred to the hospital multiple times and readmitted to the facility without any written documentation of the bed-hold policy being provided. Similarly, Resident #45 was transferred to the hospital and readmitted without any written notification of the bed-hold policy being provided to the resident or their representative. Interviews with the facility staff revealed that the process for handling the Notice of Transfer or Discharge involved multiple steps and personnel, including the nurse, the business office, and the medical records department. However, there was a lack of consistency and verification in ensuring that the written notification of the bed-hold policy was actually provided to the residents or their representatives. The Administrator, Social Services Designee, Director of Nursing, and Business Office Manager all described different aspects of the process, but none could confirm that the notifications were consistently sent out as required by the facility's policy.
Failure to Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to implement comprehensive, person-centered care plans with specific interventions for three residents out of a sample of 13. Resident #5, diagnosed with Alzheimer's disease, had a care plan that did not address specific interventions related to their condition. Resident #7, diagnosed with anxiety disorder and major depressive disorder, had a care plan that lacked specific interventions for both conditions. Resident #18, diagnosed with dementia, also had a care plan that did not address specific interventions related to their condition. Interviews with the Social Services Designee, the Minimum Data Set (MDS) Coordinator, and the Administrator confirmed that it was expected for conditions such as anxiety, depression, Alzheimer's disease, and dementia to be included in a comprehensive care plan with both pharmacological and non-pharmacological interventions. The MDS Coordinator acknowledged that correcting and updating care plans had been an ongoing concern. The Administrator also confirmed that these issues should be included in the comprehensive care plan.
Failure to Ensure Complete Hospice Care Plan and Repositioning Protocol
Penalty
Summary
The facility failed to ensure that a resident receiving hospice services had a complete hospice coordinated plan of care. Specifically, Resident #4's medical record showed that the resident was admitted to hospice on 02/27/24, but there were no facility staff signatures on the hospice coordinated plan of care dated 02/09/24. The Director of Nursing (DON) confirmed that hospice coordinated plans of care should be signed by both hospice and facility staff, indicating a lapse in the required documentation and coordination of care for the resident receiving hospice services. Additionally, the facility failed to provide necessary care and services in accordance with professional standards of practice for Resident #23, who required repositioning due to an impairment. Despite the resident's care plan indicating the need for repositioning every two hours, observations showed that the resident remained in the same position for extended periods on multiple occasions. Interviews with the resident and staff confirmed that the resident was not being repositioned as required, and the resident's plan of care did not reflect a two-hour turn schedule. The DON acknowledged that residents who cannot turn themselves should be repositioned every two hours, highlighting a failure in adhering to the care plan and repositioning protocol for Resident #23.
Improper Handling of Foley Catheter Tubing and Drainage Bags
Penalty
Summary
The facility failed to ensure proper placement and handling of Foley catheter tubing and drainage bags for two residents. Resident #4, who was admitted with an unstageable sacral wound, had an incident where a Registered Nurse used their foot to push the resident's bedside table, causing their shoe to touch the catheter tubing. This action violated the facility's policy on catheter care, which emphasizes the importance of maintaining aseptic technique and preventing catheter-associated urinary tract infections by ensuring that catheter tubing and drainage bags are kept off the floor and not touched by shoes or other objects. Resident #7, admitted with a diagnosis of benign prostatic hyperplasia, was observed multiple times with their catheter drainage bag and tubing touching the floor. The drainage bag was also not covered with a dignity bag as required. Interviews with the resident and staff, including the Director of Nursing, Registered Nurse, and Licensed Practical Nurse, confirmed that catheter bags and tubing should not touch the floor and should be kept in dignity bags. The staff acknowledged that the catheter drainage bags should be changed weekly and maintained off the floor, but these protocols were not consistently followed for Resident #7.
Improper Storage and Use of Nasal Cannulas and Oxygen Orders
Penalty
Summary
The facility failed to ensure proper storage of nasal cannulas when not in use for two residents and did not follow oxygen orders for one resident. Resident #27, diagnosed with chronic obstructive pulmonary disease (COPD), was observed with a nasal cannula lying on the floor, which was then picked up by a CNA and placed in the resident's nostrils. Resident #42, diagnosed with congestive heart failure (CHF) and atherosclerotic heart disease, was observed multiple times with the nasal cannula improperly stored or not in use while the oxygen concentrator was set at incorrect levels. The nasal cannula was found on the floor, under a pillow, or hanging from the resident's ear, and the oxygen concentrator was set at 2.5 L/min and 3 L/min instead of the prescribed 2 L/min. Interviews with the DON, RN, LPN, and the Administrator confirmed that nasal cannulas should not touch the floor and should be stored in sealed containers when not in use. The oxygen concentrator should be set according to the physician's orders. The staff acknowledged that the nasal cannulas should not be left on the floor, under a pillow, or hanging from a resident's ear, and that the concentrator settings should match the physician's orders. The facility's policy on oxygen administration was not followed, leading to these deficiencies.
Failure to Address PTSD in Resident Care Plan
Penalty
Summary
The facility failed to identify, assess, and provide supportive interventions for a resident diagnosed with post-traumatic stress disorder (PTSD). The resident, who had multiple diagnoses including PTSD, bipolar disorder, essential tremor, and dementia, was admitted to the facility on an unspecified date. Despite the resident's PTSD being documented in their medical records and a PTSD assessment indicating a history of stressful sexual experiences, the facility did not address PTSD in the resident's care plan. The care plan lacked documentation of past trauma or any triggers that could cause the resident to exhibit behaviors related to PTSD. Interviews with the resident and facility staff revealed that the resident was not informed about their PTSD diagnosis, and the facility staff did not discuss PTSD with the resident. The Social Services Designee and the Minimum Data Set (MDS) Coordinator both acknowledged that PTSD should have been included in the resident's comprehensive care plan, with appropriate pharmacological and non-pharmacological interventions. The Administrator also confirmed that PTSD should be addressed in the care plan. The failure to include PTSD in the care plan and provide necessary interventions was identified as an ongoing concern in the facility.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate of less than five percent, resulting in an error rate of 6.25%. This deficiency was identified through observation, interview, and record review. Specifically, two residents were affected by the administration of expired insulin and incorrect insulin dosages. Resident #17 received expired Novolog insulin, which was administered by a Certified Medication Technician (CMT) who was aware of the expiration but stated that the pharmacy had not sent a new supply. Resident #19 was almost administered an incorrect dosage of Novolog insulin; the CMT drew up 4 units instead of the prescribed 2 units but stopped before administration upon realizing the mistake. Both incidents indicate a failure to adhere to the facility's policies on insulin administration and medication storage, as well as the manufacturer's instructions for Novolog insulin usage and expiration dates. The Director of Nursing (DON) and the Administrator both confirmed that they expected CMTs and nurses to double-check expiration dates and insulin dosages before administration. The DON emphasized that it was the responsibility of the CMTs and nurses to ensure that expired insulin was not used and to seek alternatives if necessary. Despite these expectations, the observed practices did not align with the facility's policies, leading to the identified deficiencies in medication administration for the affected residents.
Failure to Discard Expired Insulin Vials
Penalty
Summary
The facility failed to ensure that opened, multi-use vials of insulin were discarded after the expiration date of 28 days, as per the manufacturer's instructions. During an observation of the Certified Medication Technician (CMT) medication cart, it was found that multiple vials of insulin, including Novolog, insulin aspart, Fiasp, and lispro, were opened and dated beyond the 28-day expiration period. The CMT responsible for checking the expiration dates on the cart, along with other nursing staff, incorrectly stated that insulin would expire 27 days after the opened date, which contradicts the manufacturer's guidelines of 28 days. The Director of Nursing (DON) confirmed that insulin should not be used after 28 days from the opened date and that staff are expected to check expiration dates before administering the medication. The DON also stated that expired insulin should be held and a replacement should be called for. This deficiency was identified through both observation and interviews with the CMT and DON, highlighting a lapse in adherence to medication storage and expiration protocols within the facility.
Infection Control Deficiencies
Penalty
Summary
The facility failed to maintain proper infection control practices during incontinent care, catheter care, and wound care for multiple residents. Specifically, staff members did not perform hand hygiene between glove changes, did not use gloves and gowns as required, and failed to clean contaminated surfaces such as urine-soaked mattresses. These lapses were observed during care for four residents receiving incontinent care, one resident receiving catheter care, and two residents receiving wound care. The facility's policies on hand hygiene and wound care were not followed, contributing to these deficiencies. For instance, during incontinent care for one resident, nursing assistants failed to perform hand hygiene and change gloves appropriately, and did not clean a urine-soaked mattress before placing a clean sheet on it. Similarly, during wound care for another resident, a licensed practical nurse and a registered nurse did not perform hand hygiene between glove changes, did not use gowns, and handled wound dressings and supplies without maintaining a clean field. These actions were inconsistent with the facility's infection control policies. Additionally, during catheter care for a resident, a nursing assistant did not perform hand hygiene between glove changes. Observations also revealed that staff did not follow enhanced barrier precautions, such as wearing gowns and gloves, when required. Interviews with the Director of Nursing, nursing assistants, and the Administrator confirmed that hand hygiene and glove changes should be performed as needed, and enhanced barrier precautions should be followed, but these practices were not consistently implemented.
Lack of Documentation for Vaccine Education
Penalty
Summary
The facility failed to document pertinent education provided to residents or their representatives regarding the benefits, side effects, or warnings of the influenza and pneumococcal vaccines. This deficiency was identified for four residents out of five sampled, with the facility's census being 49. Specifically, the medical records of these residents showed that they received the vaccines, but there was no documentation indicating that the facility provided the necessary information and education prior to administration. For instance, Resident #6 received the influenza vaccine on 11/20/23, but there was no documentation of education provided. Similarly, Resident #23 received both the influenza and pneumococcal vaccines, but again, no documentation of education was found in the medical records. During an interview, the Director of Nursing (DON) confirmed that education should be provided prior to any vaccine being administered and that this education should be documented. However, the facility did not have a policy regarding influenza and pneumonia immunizations, which contributed to the lack of documentation. This oversight was consistent across multiple residents, including Resident #43 and Resident #44, who also received vaccines without documented education. The absence of documented education for these vaccines indicates a systemic issue within the facility's vaccination process.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Poplar Bluff
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Manor, The | 1.5 mi | ★★★★★ | 0 | 0 |
| Aspire Senior Living Poplar Bluff | 1.5 mi | ★★★★★ | 2 | 0 |
| Oakdale Care Center | 2.3 mi | ★★★★★ | 9 | 0 |
| Westwood Hills Health & Rehabilitation Center | 2.7 mi | ★★★★★ | 6 | 0 |
| Puxico Nursing And Rehabilitation Center | 19.9 mi | ★★★★★ | 5 | 0 |
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