Average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Cotton Point Living Center during CMS and state inspections, most recent first.
Unsanitary ice machine conditions and resident access to communal ice were observed. The ice machine drain line lacked an air gap and rested directly on a floor drain, with water dripping onto the drain and dirt and debris present in the surrounding areas. In addition, a resident used a dirty cup to pour liquid into the communal ice chest and handled the ice scoop with bare hands while an LPN did not intervene or assist.
Failure to document and report a resident fall: A resident with a history of falls, wheelchair use, and assistance needs was found on the floor, but the fall was not documented, no post-fall assessment was recorded, and the provider and on-call nurse were not notified. The care plan was not updated with new fall interventions, and the resident later reported soreness from the fall and not feeling well.
Failure to provide ordered restorative therapy for two residents. One resident had an order for bilateral UE ROM, stretching, and passive/active ROM, but there was no documentation of any RT being provided and the resident was unsure whether it occurred. Another resident had an order for bilateral LE exercises, sit-to-stand/stand-to-sit, parallel bars ambulation, and NuStep, but there was no documentation that RT was provided. The RNA said RT was often not completed because he/she was pulled to the floor and refusals may not always have been charted.
Medication administration errors resulted in a 14.81% error rate, exceeding the allowed 5% threshold. An LPN failed to give a resident's statin dose and another resident's Eliquis doses were unavailable in-house for multiple missed administrations, while a third resident's blood sugar was entered incorrectly in the MAR and the ordered Humalog dose was not given. Interviews confirmed the missed doses and documentation error, and the physician stated the facility had not notified him/her that residents had missed multiple doses.
Two residents experienced significant medication errors when an LPN failed to administer ordered Eliquis doses and the MAR showed multiple missed doses because the medication was unavailable in-house. Another resident with DM had a blood sugar of 159, but an LPN entered 139 on the MAR and did not give the ordered Humalog dose for the actual reading.
Influenza immunization documentation was missing for three sampled residents. Records for residents with COPD, Alzheimer's disease, major depressive disorder, hypertension, and generalized anxiety disorder showed no documentation of vaccine education, consent or refusal, or receipt of the flu vaccine. The ADON, DON, and Administrator stated they would expect the immunization forms to be documented, and the Administrator said the IP was responsible for obtaining resident consents or refusals.
The facility failed to protect residents from various forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, due to lapses in safeguarding measures.
The facility failed to maintain a safe, clean, and homelike environment, with observations of dust, dirt, and poor maintenance in resident rooms and equipment. Staff interviews revealed inadequate communication and documentation of maintenance needs, contributing to unresolved environmental issues. Resident Council Meeting Minutes also noted concerns about wheelchair cleanliness.
The facility did not follow its policies for conducting Criminal Background Checks (CBC) and periodic Employee Disqualification List (EDL) checks for several employees. A CBC was not completed for one employee before hire, and EDL checks were not performed quarterly or annually for others, as required. Interviews revealed a lack of awareness of these requirements among staff.
The facility failed to transmit quarterly MDS assessments on time for four residents, as required by OBRA regulations. The MDS Coordinator acknowledged delays, while the Administrator expected timely completion, and the Regional Nurse Consultant believed all assessments were current.
The facility did not transmit the MDS assessments for two residents within the required 14-day period after completion, as per federal and state guidelines. The MDS Coordinator acknowledged delays, while the Administrator expected timely submissions. The Regional Nurse Consultant believed all assessments were current.
A facility failed to include PTSD-specific interventions in a resident's baseline care plan within 48 hours of admission, despite the resident's multiple diagnoses including PTSD. Interviews revealed the resident, a military veteran, experienced PTSD triggers from loud noises, and staff acknowledged the oversight in not including PTSD interventions in the care plan.
The facility failed to follow physician's orders for medications and treatments for several residents. A resident with bipolar disorder did not receive scheduled Invega Trinza injections, while another with dementia used oxygen without a physician's order. A resident in hospice care lacked a timely order, and another with mental health issues missed a scheduled Invega Sustenna dose, leading to an altercation. Staff interviews confirmed expectations for adherence to orders were not met.
The facility failed to implement and monitor nutritional interventions for two residents, resulting in significant weight loss. Despite RD recommendations for dietary changes, these were not followed, and staff did not encourage meal consumption. Observations showed one resident eating only 50% of meals without assistance, while another resident experienced severe weight loss despite eating 100% of meals provided.
The facility failed to reconcile narcotic medications at each shift change, affecting all residents. Reviews of narcotic count logs for three medication carts and the medication room revealed numerous missed opportunities for reconciliation. Interviews with staff confirmed that the facility's protocol required both on-coming and off-going staff to count narcotic medications together and sign the narcotic log book. However, the facility did not provide a policy on narcotic reconciliation documentation, contributing to the failure in ensuring consistent reconciliation practices.
The facility failed to provide appropriate diagnoses for the use of Seroquel, an antipsychotic medication, for three residents. The facility's policy requires specific conditions and documented diagnoses for such medications, but Seroquel was prescribed for unspecified dementia, behaviors, and psychosis without proper justification. Interviews confirmed that dementia is not an appropriate diagnosis for Seroquel, indicating non-compliance with the facility's guidelines.
The facility failed to maintain sanitary conditions in food storage and distribution, with missing temperature logs and undated, unlabeled food items. Observations showed a lack of proper cleaning in the kitchen, increasing the risk of cross-contamination and food-borne illness for all 54 residents.
A housekeeper in an LTC facility misused a resident's bank card for personal transactions without consent. The resident, with no cognitive impairment, was unaware until a family member noticed unusual transactions. Video footage confirmed the housekeeper's unauthorized use, leading to a police investigation. The facility's abuse prevention policy was not followed.
The facility failed to manage resident funds appropriately, leading to delayed refunds and unauthorized withdrawals for several residents. Additionally, the facility did not provide timely Social Security/Medicaid allowances, affecting residents' financial management. Interviews revealed a lack of clarity in financial processes, contributing to these deficiencies.
The facility failed to manage the resident trust fund account according to proper accounting principles by not reconciling the account monthly. The account, which managed funds for 34 residents, showed no reconciliations for several months, and attempted reconciliations did not match the residents' current balances. Interviews revealed that the reconciliations for October and November were not completed due to the workload.
The facility failed to provide timely final accounting of resident funds for two residents. A resident's funds were refunded 70 days post-discharge due to book closure delays. Another resident's trust fund withdrawal for room and board was not reported to the Department of Social Services until 107 days after their death, as the Business Office Manager was unaware of the reporting requirement.
A resident with moderately impaired cognition had their bank card misappropriated by a CNA, who used it for personal transactions. The resident's family discovered unauthorized charges, and the CNA admitted to some of the transactions. The resident confirmed they never gave permission for the card's use, highlighting a failure to adhere to the facility's abuse prevention policy.
Unsanitary Ice Machine Conditions and Resident Access to Communal Ice
Penalty
Summary
The facility failed to maintain sanitary conditions for ice intended for resident consumption. Surveyors observed that the ice machine drain line on Birch Boulevard did not maintain the required air gap and instead extended through the wall into the furnace room and rested directly on a floor drain. Water was seen dripping from the pipe onto the drain, and dirt and debris were observed on the floor in the furnace room. In the ice machine room, two plastic containers with dust were on top of the machine, dirt and debris were on the floor beneath it, and a blue ice scoop was also on the floor under the machine. Surveyors also observed a resident accessing the communal ice chest without staff intervention. A cart labeled dirty cups only was located next to a cart labeled clean cups only in the dining room. The resident removed a dirty cup, went to the ice chest near the nurse's station, opened the lid, poured liquid from the dirty cup into the communal ice chest, and used the communal ice scoop with bare hands to scoop ice into the cup twice. An LPN remained at the nurse's station and did not intervene or redirect the resident, and no staff assisted the resident with obtaining ice. The Administrator, DON, Housekeeping Supervisor, and Maintenance Supervisor all stated that residents should not obtain their own ice and that the ice machine drain line should have maintained an air gap.
Failure to Document and Report a Resident Fall
Penalty
Summary
The facility failed to monitor and consistently implement interventions to reduce falls and accidents for Resident #49, who had intact cognition, required partial to moderate assistance with toileting and sit-to-stand transfers, substantial to maximal assistance with bed mobility, and used a wheelchair. The resident’s care plan identified fall risk, a history of falls, restorative strengthening and balancing, PT consult as needed, and monitoring for changes in condition, but it did not address the fall that occurred on 05/08/26 with new interventions. The resident’s record contained no documentation of the fall on 05/08/26, no documented assessment after the fall, and no documentation that the provider or on-call nurse were notified. The facility policy titled Falls and Fall Risk, Managing required staff to identify interventions based on the resident’s risks and causes of falls, monitor and document responses to interventions, and have the nurse assess and document vital signs, injury, musculoskeletal function, cognition, neurological status, pain, precipitating factors, medications, and diagnoses after a fall. During observation on 05/11/26, the resident was seated in the dining room with food in front of him/her and did not eat. The resident told MR staff he/she did not feel well, had a fall over the weekend, and did not feel like eating. In interviews, the resident said he/she was sore from the fall and had reported it to staff. Staff interviews reflected that they expected a resident who fell to be assisted, the charge nurse informed, and the resident assessed immediately, but the LPN who found the resident on the floor stated he/she did not document the fall or notify the provider or on-call nurse.
Failure to Provide Ordered Restorative Therapy
Penalty
Summary
The facility failed to provide restorative services as ordered for two residents. One resident had a quarterly MDS showing independence for bed mobility, transfers, toileting, and mobility, with minimal assistance or supervision needed for dressing, personal hygiene, and showers. A physician order dated 04/17/26 directed restorative therapy three times per week for bilateral upper extremity therapy, passive ROM, active ROM, and stretching, but the medical record showed no documentation that the resident received restorative therapy from 04/17/26 through 05/14/26, with 12 missed opportunities out of 12. During interview, the resident said he/she did things on his/her own, did not need therapy other than help with showering on occasion, and was unsure what restorative therapy was or whether he/she received it. Another resident had a quarterly MDS showing independence for bed mobility, bathing, and transfers, minimal assistance or supervision for dressing and toileting, partial or moderate assistance with personal hygiene, wheelchair use for mobility, and impairment of both lower extremities. A physician order dated 02/03/26 directed restorative therapy three times per week, including seated bilateral lower extremity exercises with a green band and 2-lb ankle weights, sit-to-stand and stand-to-sit, ambulation in parallel bars, and NuStep for 10 minutes. The medical record showed no documentation that the resident received restorative therapy from 02/03/26 through 05/14/26, with 45 missed opportunities out of 45. The restorative nursing aide stated that if there were no notes in the EMR, then there were no notes, that he/she tried to do restorative therapy as ordered but was often pulled to the floor, and that refusals may not always have been charted.
Medication Error Rate Exceeded Allowed Threshold
Penalty
Summary
The facility failed to maintain a medication error rate of 5% or less. Surveyors identified 4 errors out of 27 opportunities for error, resulting in an error rate of 14.81%, which affected three sampled residents: one resident with hyperlipidemia, carotid artery stenosis, hypertension, venous disorders, Alzheimer's disease, and cerebrovascular disease; one resident with hyperlipidemia, atrial flutter, hypertension, and mitral valve prolapse; and one resident with type 2 diabetes mellitus. For one resident, an order for rosuvastatin calcium 40 mg daily was on the POS, but during observation an LPN prepared the medication and did not administer the dose. The MAR showed the medication had last been given on 05/06/26 and then documented as unavailable in-house for eight missed opportunities from 05/07/26 through 05/14/26. For another resident, an order for Eliquis 5 mg twice daily was on the POS, but during observation an LPN prepared the medication and did not administer the dose. The MAR showed the last morning dose was given on 05/05/26, with the evening dose that day and all doses from 05/06/26 through 05/14/26 documented as unavailable in-house, totaling 19 missed opportunities. For the third resident, an order for Humalog KwikPen sliding scale insulin was in place, and during observation an LPN checked a blood sugar of 159 but entered 139 into the MAR, told the resident zero units would be given, and did not administer the ordered 33 units for the recorded blood sugar. Interviews showed the LPN said the wrong blood sugar reading had been entered, and the ADON and Administrator stated they expected staff to double check blood sugar readings and medication administration entries. Pharmacy staff also stated the rosuvastatin calcium and Eliquis had been last ordered weeks earlier, and the physician stated the facility had not notified him/her that the residents had missed multiple doses.
Medication administration and blood sugar documentation errors
Penalty
Summary
The facility failed to ensure two residents were free from significant medication errors when medications were not administered as ordered and a blood sugar reading was documented incorrectly. One resident had diagnoses including hyperlipidemia, atrial flutter, hypertension, and mitral valve prolapse, and had an order for Eliquis 5 mg by mouth twice daily for DVT prevention. On observation, an LPN prepared the resident's medications but did not administer the Eliquis dose. The MAR showed the last Eliquis administration was the morning dose on 05/05/26, with the evening dose that day and all doses from 05/06/26 through 05/14/26 documented as unavailable in-house, totaling 19 missed opportunities out of 19. A second resident with type 2 DM had an order for Humalog KwikPen sliding scale insulin, with 33 units ordered for a blood sugar of 140 to 169. During observation, an LPN checked the resident's blood sugar at 159, told the resident the reading was 159, but entered 139 on the MAR and told the resident he or she would receive zero units of insulin. The LPN stated he or she must have entered the wrong blood sugar reading. The ADON and Administrator stated they expected staff to double check blood sugar readings and medication administration entries, and the physician stated the facility did not notify him or her that the resident had missed multiple doses of Eliquis.
Influenza Immunization Documentation Missing for Three Residents
Penalty
Summary
Develop and implement policies and procedures for flu and pneumonia vaccinations was cited after the facility failed to ensure influenza immunizations were documented or completed for three of five sampled residents. Review of the facility policy titled, "Influenza, Prevention and Control of Seasonal," dated August 2014, showed the Infection Preventionist was to promote and administer the seasonal influenza vaccine and that, unless contraindicated, all residents and staff were to be offered the vaccine. Record review for Residents #9, #13, and #15 showed no documentation of education provided to the resident or representative regarding the benefits and potential side effects of the influenza vaccine, no documentation of consent or refusal, and no documentation that the vaccine was received. Resident #9 had diagnoses of COPD and Alzheimer's disease, Resident #13 had diagnoses of major depressive disorder and hypertension, and Resident #15 had diagnoses of COPD and generalized anxiety disorder. During interviews, the ADON, DON, and Administrator each stated they would expect immunization forms to be documented, and the Administrator stated the IP was responsible for obtaining residents' consents or refusals for immunizations.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report notes that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure resident safety and well-being. No specific details about the actions, inactions, or events leading to the deficiency, nor information about the residents involved or their medical conditions at the time, are provided in the report.
Facility Fails to Maintain Safe and Clean Environment
Penalty
Summary
The facility failed to provide a safe, clean, and comfortable homelike environment for its residents, as evidenced by multiple observations of unclean and poorly maintained areas within the facility. Specific observations included a buildup of dust and dirt on air filters, long dark markings on walls, exposed sheetrock, and peeled paint in several rooms. Additionally, there was a buildup of dried food and dirt on a resident's wheelchair and grime on a Hoyer lift. A missing vent cover was also noted in the resident private phone room. These conditions were observed over multiple days, indicating a persistent issue with maintaining a clean and homelike environment. Interviews with facility staff revealed a lack of effective communication and documentation regarding maintenance needs. The Maintenance Supervisor acknowledged being aware of the numerous repairs and painting required but expressed difficulty in keeping up with tasks due to the informal way staff communicated these needs. The Administrator also recognized the environmental concerns and emphasized the importance of staff documenting issues in the maintenance log rather than relying on verbal communication. The February 2025 Resident Council Meeting Minutes further highlighted concerns about the cleanliness of resident wheelchairs, indicating that these issues were known to both staff and residents.
Failure to Conduct Required Background and Disqualification Checks
Penalty
Summary
The facility failed to adhere to its policies and procedures regarding Criminal Background Checks (CBC) and Employee Disqualification List (EDL) checks for several employees. Specifically, the facility did not complete a CBC for Employee I prior to their hire date, as required by the facility's policy. Additionally, the facility did not perform periodic checks of the EDL for Employees G, I, J, K, L, and M, as mandated by their policy. The policy requires that the EDL be checked at the time of hire and periodically thereafter, including quarterly and annually, to ensure that employees have not been placed on the list for abuse, neglect, or misappropriation of funds or property from residents. Interviews with the Human Resources staff and the Administrator revealed a lack of awareness and understanding of the requirements for EDL checks beyond the initial hire. The HR staff was unaware of the need for periodic checks, while the Administrator believed that checks should occur at least quarterly. This oversight resulted in the facility not conducting the necessary EDL checks for the sampled employees, which is a deviation from the established policies designed to prevent abuse, neglect, and theft within the facility.
Failure to Timely Transmit Quarterly MDS Assessments
Penalty
Summary
The facility failed to electronically transmit quarterly Minimum Data Set (MDS) assessments in a timely manner for four residents, two of whom were part of the sample and two who were not. The facility's policy requires that comprehensive assessments be completed at intervals designated by OBRA regulations and PPS requirements, with data submitted to the Internet Quality Improvement Evaluation System (iQIES) as required. However, the facility did not complete quarterly MDS assessments for Residents #37, #38, #40, and #42 within the required 92-day timeframe from the last MDS assessment. Interviews conducted during the investigation revealed that the MDS Coordinator, who was new to the position, acknowledged that some MDS assessments were behind schedule. The Administrator expressed an expectation for timely completion of MDS assessments, while the Regional Nurse Consultant was under the impression that all MDS assessments were up to date. This discrepancy highlights a communication and procedural lapse within the facility, leading to the failure in meeting the federally mandated assessment timelines.
Failure to Timely Transmit MDS Assessments
Penalty
Summary
The facility failed to electronically transmit the Minimum Data Set (MDS) assessments for two residents in a timely manner, as required by federal and state guidelines. Resident #17 and Resident #41 both had quarterly MDS assessments completed but not transmitted within the mandated 14-day period following the completion date. The facility's policy, dated October 2023, stipulates that MDS assessments must be conducted and submitted according to the current requirements published in the Resident Assessment Instrument (RAI) Manual. During interviews, the MDS Coordinator acknowledged being aware of some assessments being behind or late, while the Administrator expressed an expectation for timely submissions. The Regional Nurse Consultant was under the impression that all MDS assessments were up to date.
Failure to Address PTSD in Baseline Care Plan
Penalty
Summary
The facility failed to include an admitting diagnosis of post-traumatic stress disorder (PTSD) with specific interventions on the baseline care plan for a resident within 48 hours of admission. The resident, who was admitted with multiple diagnoses including PTSD, paranoid schizophrenia, schizoaffective disorder, major depression disorder, irritability, and anger, did not have PTSD-specific interventions addressed in the baseline care plan. This omission was identified during a review of the resident's medical record and baseline care plan. Interviews conducted with the resident and facility staff revealed that the resident, a military veteran, experienced PTSD triggers from loud noises. The Social Service Director noted that the resident avoided discussing PTSD shortly after admission. The Director of Nursing and the Administrator both acknowledged that a PTSD diagnosis should have been included in the baseline care plan with specific interventions. This oversight indicates a failure to adhere to the facility's policy requiring a baseline care plan to meet immediate health and safety needs within 48 hours of admission.
Failure to Follow Physician's Orders for Medications and Treatments
Penalty
Summary
The facility failed to obtain and follow physician's orders for several residents, leading to deficiencies in care. Resident #2, diagnosed with bipolar disorder and major depressive disorder, had a physician's order for Invega Trinza to be administered intramuscularly every three months. However, the medication was not administered as scheduled in November 2024 and February 2025. Resident #15, with diagnoses including dementia and COPD, was observed using an oxygen concentrator without a corresponding physician's order, despite experiencing difficulty breathing. The Director of Nursing and the Administrator acknowledged the absence of a necessary order for oxygen. Resident #37, diagnosed with hypertension, congestive heart failure, and atrial fibrillation, was admitted to hospice care without a physician's order until March 2025, despite being in hospice since July 2024. Resident #158, with multiple mental health diagnoses, had an order for Invega Sustenna to be administered monthly, but the medication was not given as scheduled in February 2025. This resident was involved in a resident-to-resident altercation shortly after the missed medication. Interviews with staff, including the Regional Nurse Consultant and the Administrator, revealed an expectation for nursing staff to document medication administration and adhere to physician's orders, which was not met in these cases.
Failure to Implement Nutritional Interventions for Residents
Penalty
Summary
The facility failed to implement, monitor, and modify interventions to maintain acceptable nutritional status for two residents. Resident #19 experienced a severe weight loss of 8.11% over three months, from November 14, 2024, to February 7, 2025. Despite recommendations from the Registered Dietitian (RD) to add ice cream and health shakes to the resident's diet, these were not provided, and staff did not encourage the resident to eat meals. Observations showed the resident eating only 50% of meals without assistance, and the facility did not address the RD's recommendations. Resident #40 experienced a severe weight loss of 6.9% in one month and 11.3% over six months. The RD recommended increasing health shakes and liberalizing the diet to allow more food choices. However, the facility failed to implement these recommendations. Observations showed the resident eating 100% of meals and ice cream provided, but the necessary dietary changes were not made. Interviews with staff revealed a lack of follow-through on RD recommendations and a failure to address significant weight changes in a timely manner.
Failure to Reconcile Narcotics at Shift Change
Penalty
Summary
The facility failed to ensure proper reconciliation of narcotic medications at each shift change, affecting all residents. The review of narcotic count logs for three medication carts and the medication room revealed numerous missed opportunities for reconciliation. Specifically, the 100 Hall Medication Cart showed 13 missed reconciliations out of 44 opportunities for one shift period and 6 missed out of 21 for another. The 200 Hall Medication Cart had 22 missed reconciliations out of 47 opportunities, and the 300 Hall Medication Cart had 20 missed out of 42 opportunities. Additionally, the Medication Room showed 10 missed reconciliations out of 35 opportunities for one shift period, 13 missed out of 35 for another, and 4 missed out of 13 for a subsequent period. Interviews with staff, including an LPN, the Regional Nurse Consultant, and the Administrator, confirmed that the facility's protocol required both on-coming and off-going staff to count narcotic medications together and sign the narcotic log book. However, the facility did not provide a policy on narcotic reconciliation documentation, which contributed to the failure in ensuring consistent reconciliation practices. This deficiency had the potential to affect all residents in the facility, which had a census of 54.
Inappropriate Use of Antipsychotic Medication Due to Lack of Proper Diagnosis
Penalty
Summary
The facility failed to ensure an appropriate diagnosis for the use of psychotropic medication for three residents out of five sampled. The facility's policy on antipsychotic medication use, revised in July 2022, stipulates that such medications should only be administered when necessary to treat specific conditions and must be supported by documented diagnoses consistent with the Diagnostic and Statistical Manual of Mental Disorders. However, the facility did not provide appropriate diagnoses for the use of Seroquel, an antipsychotic medication, for three residents. Resident #1 was prescribed Seroquel for unspecified dementia, Resident #15 for behaviors, and Resident #20 for psychosis, but none of these prescriptions were supported by appropriate diagnoses as per the facility's policy. Interviews with the Regional Nurse Consultant and the Administrator confirmed that dementia is not an appropriate diagnosis for prescribing Seroquel. The facility's failure to adhere to its policy on antipsychotic medication use resulted in the inappropriate prescription of Seroquel for these residents. This deficiency highlights a lack of compliance with the facility's own guidelines, which require specific conditions and documented diagnoses to justify the use of antipsychotic medications.
Deficient Food Storage and Sanitation Practices
Penalty
Summary
The facility failed to maintain sanitary conditions in food storage and distribution, as observed during a survey. There were no food temperature logs for the period from February 22 to March 4, and refrigerator temperature logs were missing from March 1 to March 4. Observations revealed undated and unlabeled food items in the refrigerators, including opened biscuits, frozen pancakes, French fries, red jello, boiled eggs, shredded cheese, and butter. Additionally, the dishwasher machine had a buildup of debris, crumbs, and a hard white substance, indicating a lack of proper cleaning. Interviews with the Dietary Manager, Registered Dietician, and Administrator confirmed that the facility's policies required daily checks and logs of food and refrigerator temperatures, as well as daily cleaning of kitchen equipment. All foods were expected to be labeled, dated, and secured to prevent contamination. The failure to adhere to these policies increased the risk of cross-contamination and food-borne illness, potentially affecting all 54 residents in the facility.
Misappropriation of Resident's Bank Card by Housekeeper
Penalty
Summary
The facility failed to protect a resident from the wrongful use of their belongings, specifically a bank card, by a staff member. The incident involved a housekeeper who used the resident's bank card for personal transactions without consent. The resident, who had no cognitive impairment, was unaware of the card's misuse until a family member noticed unusual transactions and notified the facility. The housekeeper was identified through video footage using the card at a gas station ATM, correlating with the times and locations provided by the bank. The resident's family reported the incident to the facility's Director of Nursing, who then informed the Administrator and assisted in notifying the police. The police investigation confirmed the housekeeper's unauthorized use of the card, with video evidence from both the gas station and the facility supporting the claim. The housekeeper was seen entering the resident's room and later using the ATM, withdrawing a significant amount of money. Interviews with other staff members revealed that the housekeeper had asked for rides to the gas station under false pretenses, claiming personal reasons unrelated to the resident's card. The housekeeper denied the allegations, despite the evidence against them. The facility's policy on abuse prevention, which the housekeeper had acknowledged, was not followed, leading to the misappropriation of the resident's property.
Deficiencies in Resident Financial Management
Penalty
Summary
The facility failed to ensure that resident funds were managed appropriately, leading to several deficiencies. Specifically, the facility did not place resident funds in an account separate from the facility's operating account, resulting in delayed refunds for 12 residents. Additionally, the facility staff did not obtain written authorization for withdrawals from the accounts of five residents, which included duplicate charges and unauthorized withdrawals for room and board, cigarettes, and shopping expenses. The facility also failed to provide the Social Security and/or Medicaid monthly allowance in a timely manner for five residents, which hindered their ability to manage their financial affairs. This issue was compounded by the facility's inability to close the books for a specific month, further delaying the disbursement of allowances. Interviews with the Interim Administrator and Business Office Manager revealed a lack of clarity and control over the financial processes, contributing to these deficiencies. The report highlights specific instances where residents' financial rights were not honored, such as duplicate room and board charges for a resident who was hospitalized and unauthorized withdrawals for clothing and other personal expenses. The facility's failure to manage resident funds properly and obtain necessary authorizations reflects a significant oversight in financial management practices, impacting the residents' ability to manage their own financial affairs.
Failure to Reconcile Resident Trust Fund Account
Penalty
Summary
The facility failed to maintain a system to ensure the resident trust fund account was managed in accordance with proper accounting principles. Specifically, the facility did not maintain an accurate accounting of all monies held in the resident trust fund account by failing to reconcile the account each month. The facility managed funds for 34 residents, with a total census of 53. Record reviews of the facility-maintained bank statements for the account ending in 2107 from December 2023 through November 2024 showed no documentation of reconciliations for several months, including December 2023, June 2024, July 2024, September 2024, October 2024, and November 2024. Additionally, attempted reconciliation forms for the same account from December 2023 through September 2024 did not reconcile to the residents' current balance at the time of the attempted reconciliation, and there were no attempted reconciliations for October 2024 through November 2024. Interviews with the Regional Accountant and Business Office Manager revealed that the books for October 2024 and November 2024 had not been closed out, and the reconciliations for these months were not completed due to the amount of financial work.
Delayed Final Accounting of Resident Funds
Penalty
Summary
The facility failed to provide a final accounting of resident fund balances within the required thirty days for two residents. Resident #18 was discharged, and their funds were not refunded until 70 days after discharge, as confirmed by the Regional Accountant, who attributed the delay to closing out the books. Additionally, Resident #16 expired, and a withdrawal of $734.64 was made from their trust fund to pay for room and board. This transaction was not reported to the Department of Social Services, Third Party Liability Unit, until 107 days after the resident's death. The Business Office Manager stated that the resident's guardian instructed the payment, but they were unaware that the transaction needed to be reported to the relevant department.
Misappropriation of Resident's Bank Card by CNA
Penalty
Summary
The facility failed to protect a resident from the misappropriation of their property when a Certified Nurse Aide (CNA) used the resident's bank card for personal transactions. The resident, who had a moderately impaired cognition due to conditions such as metabolic encephalopathy, type 2 diabetes mellitus, heart failure with a pacemaker, anxiety, and depression, reported the bank card missing. The resident's family member discovered unauthorized transactions on the bank statement, including transfers to the CNA's account and an online shopping charge. The CNA admitted to using the resident's bank card for two transactions but denied the larger online shopping charge. The resident confirmed they never gave permission for the CNA to use the card and did not receive any items or food as claimed by the CNA. The facility's policy on abuse prevention, which includes misappropriation of resident property, was not followed by the CNA, leading to the deficiency.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 51 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Matthews
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Annie's Garden Skilled Nursing | 6.9 mi | — | 0 | 0 |
| Delta South Nursing & Rehabilitation | 7.4 mi | ★★★★★ | 8 | 0 |
| Hunter Acres Caring Center | 8.5 mi | ★★★★★ | 0 | 0 |
| Sikeston Convalescent Center | 8.8 mi | ★★★★★ | 9 | 0 |
| Clearview Nursing Center | 9 mi | ★★★★★ | 14 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.