Average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 E W Thompson Health & Rehabilitation Center during CMS and state inspections, most recent first.
Staff failed to follow facility policy requiring documentation of medication administration and treatments, resulting in missing MAR entries for two residents. One cognitively intact resident with dementia and on Levothyroxine, Eliquis, Tamsulosin, and Donepezil had undocumented doses on specific days. Another cognitively intact resident with heart failure, ordered Metoprolol Tartrate and twice-daily wound care with Chymosin and zinc to the right inner buttock, had multiple days without documented treatments and one day without documented Metoprolol administration. An LPN, the administrator, the DON, and the ADON all stated that staff must document completed or refused medications and treatments, and the ADON acknowledged that the monthly review of MARs and treatment records for that month was not completed due to covering MDS duties.
Staff failed to administer and/or document physician-ordered nutritional supplement shakes for a cognitively intact resident on multiple days, with the MAR lacking entries for administration or refusal of the supplements. Leadership, including the administrator, DON, and ADON, stated that staff are required to document all administered or refused supplements and that monthly MAR/TAR reviews are expected, but the ADON reported that the February review was not completed due to covering additional MDS duties.
A resident, assessed as cognitively intact with dementia and OCD and requiring substantial to maximum assistance for toileting, was subjected to verbal and emotional abuse by a CNA who repeatedly demanded independent toileting, used aggressive language, and forcefully handled the resident without a gait belt. The incident was witnessed by another aide and the resident's family, who provided video evidence confirming the abusive interaction.
Facility staff failed to follow hand hygiene protocols, washing hands for less than the required time and turning off faucets with bare hands, risking cross-contamination. Despite training, a cook and dietary aides did not adhere to procedures, as observed during a survey.
The facility failed to submit complete and accurate direct care staffing information to CMS through the PBJ system from January to July 2024. This occurred due to a transition to a new payroll company, which did not fulfill its task of handling PBJ submissions. As a result, the facility missed submission deadlines for Fiscal Quarters 1 and 2, leading to a One Star Staffing Rating. The HR manager had to manually enter the data after realizing the oversight.
The facility experienced a 16% medication error rate due to improper insulin administration and documentation lapses. CMTs failed to prime insulin pens for diabetic residents, and a CMT did not document or communicate a missing dose of Doxycycline for a resident with dementia. The DON and Administrator were unaware of these issues, highlighting gaps in staff training and adherence to policies.
Failure to Document Medication Administration and Complete Ordered Treatments
Penalty
Summary
Facility staff failed to meet professional standards of practice by not documenting medication administration and not completing ordered treatments for two residents. For one resident with dementia who was cognitively intact and prescribed Levothyroxine, Eliquis, Tamsulosin, and Donepezil, review of the Medication Administration Record (MAR) for a specified month showed no documentation that Levothyroxine was administered on one date, and no documentation that Eliquis, Tamsulosin, and Donepezil were administered on another date. The facility’s Administering Medications policy directed staff to administer medications as prescribed, to initial the MAR after giving each medication and before administering the next, and to circle and annotate the MAR if a drug was withheld, refused, or given at a time other than scheduled. For a second cognitively intact resident with heart failure, with orders for Metoprolol Tartrate and a wound care treatment to cleanse the right inner buttock and apply Chymosin and zinc twice daily, the MAR for the same month lacked documentation that the wound treatment was completed on multiple specified dates and that Metoprolol Tartrate was administered on one date. Interviews with an LPN, the administrator, the DON, and the ADON confirmed that staff were expected to document all completed medications and treatments, or refusals, in the medical record and to enter a reason if a task was not completed. The ADON stated that he/she and the DON were responsible for monthly review of MARs and treatment records but acknowledged that the February MARs and treatment records were not checked because the ADON was covering the MDS Coordinator position and did not have time to perform the review.
Failure to Administer and Document Ordered Nutritional Supplements
Penalty
Summary
Facility staff failed to administer and document physician-ordered nutritional supplement shakes for a cognitively intact resident. The resident’s Annual MDS indicated the resident was cognitively intact, and the Physician Order Summary contained an order for meal supplement health shakes. Review of the Medication Administration Record (MAR) for the month showed multiple dates on which there was no documentation that the ordered nutritional supplement shakes were administered as directed, including on 02/01, 02/03, 02/05, 02/07, 02/08, 02/09, 02/11–02/15, and 02/19. There was also no documentation that the resident refused the supplements on those dates. During interviews, the administrator stated that staff are directed to document in the medical record when supplemental shakes are given or refused. The DON similarly stated that staff are to document completed medication administration, including supplemental shakes or refusals, in the medical record, and that the ADON is responsible for reviewing MARs monthly to ensure they are complete. The ADON confirmed that once medications, including supplemental shakes, are administered, staff should document this in the electronic medical record, and that he/she and the DON review MARs and TARs monthly. The ADON acknowledged that the February MARs and TARs were not checked because he/she was filling in for the MDS Coordinator and did not have time to complete the review.
Resident Subjected to Verbal and Emotional Abuse During Toileting Assistance
Penalty
Summary
Facility staff failed to protect a resident from verbal and emotional abuse during a toileting episode involving two staff members. Certified Nurse Aide (CNA) B repeatedly demanded that the resident perform toileting tasks independently, despite the resident's inability to do so. CNA B used aggressive language, telling the resident to turn around and sit on the toilet, and expressed frustration about the time being spent with the resident. The resident, who was cognitively intact but diagnosed with dementia and obsessive-compulsive disorder, required substantial to maximum assistance for toileting according to the Minimum Data Set (MDS) assessment. During the incident, CNA B forcefully grabbed the resident under the right arm and jerked the resident up to a standing position without the use of a gait belt, which is contrary to safe transfer practices. CNA B continued to use demanding and inappropriate language, stating that they could not spend more time with the resident and that the resident was not cooperating. The interaction was witnessed by another nurse aide (NA C), who confirmed that CNA B became rude and demanding, and by the resident's family, who recorded the incident on video. The deficiency was identified after the resident's family reviewed the video footage and reported the incident to facility staff. The video and subsequent interviews confirmed that CNA B's actions and communication were verbally and emotionally abusive, and that the resident was not provided with the necessary assistance for toileting as required by their care plan and assessment.
Failure to Adhere to Hand Hygiene Protocols
Penalty
Summary
The facility staff failed to adhere to proper hand hygiene protocols, as observed during a survey. The facility's Food and Nutrition Services Hand Washing policy and Handwashing/Hand Hygiene policy outlined specific procedures for handwashing, including washing hands for a minimum of 20 seconds and using a paper towel to turn off the faucet. However, multiple staff members, including a cook and dietary aides, were observed not following these procedures. They washed their hands for significantly less time than required and turned off faucets with their bare hands, which could lead to cross-contamination. On several occasions, the cook was seen washing hands inadequately and turning off the faucet with wet hands after handling soiled gloves and trash can lids, which are considered dirty. Despite being trained on proper hand hygiene, the cook admitted to not following the procedures due to being in a hurry. Similarly, dietary aides were observed washing their hands for only a few seconds and not using paper towels to turn off the faucet, even after handling soiled dishes and equipment. Interviews with the staff, including the Dietary Manager and the administrator, confirmed that all personnel were trained on hand hygiene procedures upon hire. They acknowledged the importance of washing hands for the recommended duration and using paper towels to prevent contamination. However, the observations indicated a consistent failure to comply with these protocols, leading to a deficiency in maintaining proper hygiene standards in the facility.
Failure to Submit Timely PBJ Data
Penalty
Summary
The facility failed to electronically submit complete and accurate direct care staffing information to the Centers for Medicare and Medicaid Services (CMS) through the Payroll Based Journal (PBJ) system from January 1, 2024, through July 31, 2024. This deficiency was identified during a review of the facility's Reporting Direct Care Staffing Information policy and the CMS Electronic Staffing Data Submission Payroll-Based Journal Policy Manual. The facility's policy required that staffing information be submitted on a schedule specified by CMS, no less frequently than quarterly, and within 45 days after the end of each fiscal quarter. However, the facility did not meet these requirements, resulting in a One Star Staffing Rating for the period of July 1-September 30. The deficiency occurred due to a transition in payroll administration to a new company in February, which was expected to handle the PBJ submissions. However, the new company failed to fulfill this task, leading to the facility missing the submission deadlines for Fiscal Quarters 1 and 2. The HR manager had to manually convert and enter the PBJ information for both quarters after realizing the submissions were not made timely. Interviews with the administrator and HR manager confirmed the oversight and the facility's ultimate responsibility for the PBJ submissions.
Medication Administration Errors and Documentation Lapses
Penalty
Summary
The facility staff failed to maintain a medication error rate of less than 5%, resulting in a 16% error rate during the survey. This deficiency was observed in the administration of insulin to residents with diabetes, where Certified Medication Technicians (CMTs) did not prime insulin pens before administration. Specifically, CMT B administered insulin to three residents without priming the insulin pens, which is a necessary step to ensure the correct dosage is delivered. This oversight was confirmed through observations and interviews, where CMT A admitted to being unaware of the priming requirement due to insufficient training. Additionally, the facility's medication administration practices were found lacking in documentation and timely communication. For instance, CMT A failed to administer a prescribed dose of Doxycycline to a resident with dementia and anxiety disorder, as the medication was not found in the cart. The CMT did not document the omission in the Medication Administration Record (MAR) or notify the supervisor promptly, which is against the facility's policy. This lapse in procedure was acknowledged by the CMT during an interview, citing being busy as the reason for the delay in communication. The Director of Nursing (DON) and the Administrator were both unaware of the staff's lack of knowledge regarding insulin pen priming and the failure to follow medication administration policies. The DON confirmed that priming is essential to ensure the correct insulin dose, while the Administrator emphasized the expectation for staff to adhere to physician orders and manufacturer instructions. The Administrator also noted a discrepancy between the current practice and the documented policy regarding how to handle missing medications in the MAR.
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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 Sedalia
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Sylvia G Thompson Residence Center, Inc | 0.3 mi | ★★★★★ | 13 | 0 |
| Fair View Health Care Center | 1.6 mi | ★★★★★ | 1 | 0 |
| Rest Haven Health Care Center | 3 mi | ★★★★★ | 4 | 1 |
| Four Seasons Living Center | 6.8 mi | ★★★★★ | 32 | 1 |
| Good Samaritan Care Center | 17.4 mi | ★★★★★ | 0 | 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 July 2026) and official state health department websites.