Below average — CMS composite of the measures below.
The next survey window likely opens around September 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 Sylvia G Thompson Residence Center, Inc during CMS and state inspections, most recent first.
Facility staff did not ensure that multiple nurse aides who had been employed for more than four months completed required CNA training and certification within the mandated timeframe, and personnel files lacked documentation of program completion. Several NAs reported working independently on the floor and performing resident care while either still in CNA classes, having recently finished classes but not yet tested, or awaiting authorization to test. The facility’s policies did not address required timeframes for CNA training completion, Human Resources acknowledged terminating and then rehiring some uncertified NAs, the administrator was aware that some NAs were beyond the four‑month limit without certification, and the DON stated they were unaware that NAs had exceeded the four‑month period and were not involved with HR decisions.
The facility did not staff according to its Facility Assessment and had repeated CNA shortages across shifts while the census remained about 117 to 118 residents. The DON and administrator said staffing gaps were due to no-shows and call-ins, and administrative staff sometimes worked the floor. Wireless call light reports showed multiple delays far beyond the facility’s expected response time, including calls lasting 30 minutes to nearly 3 hours. Residents reported waiting over 30 minutes to an hour for help with toileting and transfers, with some experiencing bladder accidents or bowel incontinence during the delays.
Ice Machines Lacked Air Gaps and One Contained Visible Contamination. Two of three ice machines used to supply ice to residents were observed without an air gap in the drain setup, including one in the clean utility room and one at the nurse station 2 dining room. The clean utility room ice machine also had a black speckled substance above the ice storage bin. The Safety Coordinator and administrator gave conflicting information about responsibility for cleaning and maintenance, and the administrator was unaware of the missing air gaps and visible material.
Staff failed to properly label and securely store medications, including insulin and controlled substances, with multiple instances of opened and undated vials and pens, expired and unlabeled medications, and controlled drugs left outside of locked storage. During medication administration, staff left medications unattended on top of carts in resident-accessible areas, contrary to facility policy and staff knowledge.
Failure to Document Ordered Treatments: Staff did not document multiple ordered wound and skin treatments, as well as oxygen equipment changes, for three residents with severe cognitive impairment and pressure-related wounds/skin issues. RNs and the DON stated treatments are expected to be signed off on the TAR when completed, but the TARs contained multiple missing entries and the administrator believed staff may have forgotten to sign off.
Unsafe mechanical lift transfers occurred when staff failed to use the lift legs consistently and allowed a wheelchair to bump the lift while a resident was suspended. Two dependent residents were involved: one with severe cognitive impairment, heart failure, neuropathy, and hemiplegia, and another who was cognitively intact with heart failure, diabetes, anxiety, depression, and spinal stenosis. Staff interviews showed confusion about whether the lift legs should be open or closed for the larger wheelchair, and one CNA said he/she had not been trained on the transfer.
Quarterly bed rail assessments were missing for six residents whose records showed bed rails in use. Several residents had cognitive impairment or needed assistance with toileting, transfers, or rolling in bed, and staff observed bilateral or quarter-length side rails upright in multiple rooms. The MDS Coordinator said the assessments were his/her responsibility but some were not completed because he/she was busy, and the RN, DON, and Administrator stated quarterly assessments were expected.
Facility staff failed to ensure multiple nurse aides completed CNA training within the required 4-month timeframe. Record review showed several aides had hire dates extending beyond the allowed period, yet their files lacked documentation of completed nurse aide training. One NA stated he/she had completed online classes but had not taken or scheduled the test. The Administrator said aides had finished classes but had not passed the test and was unaware they had to be certified within 4 months; the DON said the Administrator handled training and scheduling and was unsure of the required time frames.
Medication administration errors exceeded the allowed rate, with 9 errors in 25 observed opportunities for a 36% error rate. A resident received multiple morning meds and nebulizer treatments late, and another resident received Lidocaine patches late and at the wrong dose. Staff stated that late administration and wrong dosage were medication errors.
A deficiency was cited when a facility area was not kept free from accident hazards and supervision was inadequate to prevent accidents. The environment was not properly maintained to minimize risks, and supervision protocols were insufficient, leading to the deficiency.
The facility did not complete the care plan within 7 days of the comprehensive assessment, and the care plan was not prepared, reviewed, and revised by a team of health professionals as required.
The facility failed to submit accurate direct care staffing information to CMS for July to September 2024 due to issues with a new payroll management company. HR was responsible for the submission, and both HR and the administrator were aware of the ongoing problems with data uploads.
Facility staff failed to verify medications against the MAR for two residents, relying instead on cheat sheets for insulin dosages. An LPN and an RN administered insulin without checking the MAR, contrary to facility policy. The DON and Administrator acknowledged the use of cheat sheets but stressed the importance of MAR verification.
Facility staff failed to provide safe mechanical transfers for two residents, with CNAs operating lifts with closed legs, contrary to policy. Hazardous materials were found unsecured in shower rooms and storage areas, accessible to residents. Medication carts were left unattended with medications on top, violating storage protocols. The DON and administrator confirmed these practices were unsafe and against facility policies.
The facility exceeded the acceptable medication error rate, with errors affecting two residents. A CMT failed to re-administer a pill that a resident spit out and did not hold the lacrimal duct after administering eye drops. Another CMT also did not hold the lacrimal duct after administering eye drops. Both acknowledged their errors, and the DON and Administrator confirmed these actions as medication errors.
Facility staff failed to store medications securely and discard expired ones, with unlocked refrigerators containing controlled drugs and expired medications found in medication rooms and carts. Staff interviews revealed a lack of awareness and reporting regarding missing locks on refrigerators, and inconsistent checking of expiration dates due to busy schedules. The DON and Administrator were unaware of these issues, emphasizing the need for secure storage and monitoring of medications.
The facility staff failed to serve correct meal portions as per standardized recipes, affecting all residents. Observations showed residents received less than the directed portions of beef goulash, salad, and cubed potatoes. Staff did not verify serving utensils, and a lack of training contributed to the issue. The dietary manager was unaware of the day shift cook's training needs, leading to incorrect portion sizes being served.
Facility staff failed to follow infection control practices during medication administration for several residents. CMTs were observed handling medications with bare hands and not wearing gloves while administering eye drops, contrary to facility policies. These actions were confirmed by the DON and Administrator as violations of infection control procedures.
Facility staff failed to report two allegations of resident abuse involving three residents to DHSS within the required two-hour timeframe. A resident with severe cognitive impairment was involved in altercations with two other residents, but these incidents were not reported promptly. Another incident involving a different resident was also not reported in time. The facility's administrator expressed doubts about the accuracy of staff reports, suggesting possible exaggeration of incidents.
Facility staff failed to investigate allegations of abuse involving three residents, despite policy requirements. A resident with severe cognitive impairment was involved in altercations with two other residents, but the incidents were not documented or reported to the administrator. Conflicting staff accounts and lack of timely reporting led to a failure in investigation and documentation.
The facility failed to develop comprehensive care plans for residents with severe cognitive impairment and dementia, despite documented altercations. A system hack led to the loss of documentation, and although systems were restored, care plans were not updated. Staff were unsure of interventions or access to care plans, relying on incomplete care requirement sheets.
Noncompliance With CNA Training and Certification Timeframes for Multiple Nurse Aides
Penalty
Summary
Facility staff failed to ensure that nurse aides who had worked more than four months completed a nurse aide training program within the required timeframe, and that appropriate documentation of completion was maintained. Review of personnel files for five nurse aides (NA A, NA B, NA C, NA D, and NA E) showed hire dates in late October and early November 2025, with no documentation that any of them had completed the nurse aide training program. The facility’s policies did not include guidance on the required timeframe for completion of nurse aide training. Human Resources reported that some nurse aides had been terminated in October 2025 because they were not certified and then rehired, and the administrator acknowledged awareness that a few nurse aides were beyond the four‑month timeframe without certification. Interviews with the involved nurse aides confirmed that they had been working independently on the floor and performing resident care despite not having completed certification. NA A stated they had worked as an NA since 2025, were supposed to be done with the CNA class, and were waiting on an email to take the test, while working the floor alone and providing resident care. NA C reported working as an NA since April 2025, having finished the CNA class a few weeks prior but still awaiting testing, and also working independently providing resident care. NA D stated they had worked the floor for two years as an NA, were currently in CNA classes that began in November, and still had one or two classes left due to cancellations. The DON stated awareness that several NAs were working but was not aware that some were past the four‑month limit, and reported having no involvement with Human Resources or knowledge of the terminations and rehires related to lack of certification.
Insufficient Staffing and Delayed Call Light Response
Penalty
Summary
The facility failed to provide enough nursing staff each day to meet resident needs and failed to maintain staffing consistent with its Facility Assessment. The assessment, dated 08/28/25, identified staffing goals that included specific RN, LPN, and CNA coverage by shift, including a CNA ratio goal of one to eight and a day-to-day average of one to ten. However, census and schedule reviews showed repeated shifts where CNA staffing was below the assessment goals, including evenings and nights with fewer CNAs than expected and some days with reduced direct care staffing despite a census of 117 to 118 residents. The DON and administrator stated that the facility used the Facility Assessment as a staffing goal but did not always staff according to it because of no-shows and call-ins. They said administrative staff would work the floor when needed. The facility’s policy on answering call lights directed staff to answer resident call systems immediately, but the policy did not specify who could answer call lights. Staff interviews showed expectations that call lights should be answered within two to five minutes, and both the DON and administrator said anything over 20 minutes was a concern or too long. Wireless call light reports documented multiple prolonged response times, including calls lasting 30 minutes, 40 minutes, 51 minutes, 1 hour and 21 minutes, 2 hours and 59 minutes, and other extended delays across several shifts. Residents reported waiting over 30 minutes to an hour for help with toileting and transfers, with some stating that the delays caused bladder accidents or bowel incontinence. One resident said the long waits led him/her to eat dinner in the room to avoid waiting to return from the dining room, and another said the delays made him/her feel uncared for and afraid to attempt moving alone because of fall concerns.
Ice Machines Lacked Air Gaps and One Contained Visible Contamination
Penalty
Summary
Food was not stored, prepared, distributed, and served in accordance with professional standards when two of three ice machines used to supply ice to residents were observed without an air gap in the drainage setup. During the Life Safety Code tour, the ice machine in the clean utility room had two small white plastic tubes draining from the rear of the machine into a larger white plastic floor drain without an air gap, and the white plastic above the ice storage bin contained a black speckled substance. The nurse station 2 dining room ice machine also had a black drain hose running into a white plastic drain without an air gap. In interview, the Safety Coordinator stated the contracted vendor was responsible for cleaning the ice machines but did not know how often, and said maintenance staff were responsible for plumbing but did not know about the air gap requirement. The administrator stated maintenance staff were responsible for the ice machines, was familiar with air gap requirements, but did not know the two machines lacked air gaps and was not aware of the black material in the ice machine.
Improper Medication Labeling and Storage
Penalty
Summary
Facility staff failed to ensure that drugs and biologicals were labeled and stored in accordance with professional standards and facility policy. Observations revealed multiple instances of insulin vials and pens that were opened and undated, as well as insulin pens lacking resident identification. Additionally, a bottle of Tums was found opened, unlabeled, and expired in a medication cart. Controlled medications, specifically Tramadol tablets, were found improperly stored on a countertop rather than in a locked compartment. Staff interviews confirmed that these practices were inconsistent with facility policy, which requires proper labeling, dating, and secure storage of all medications, including the use of double locks for controlled substances. Further observations showed that during medication administration, staff left medications unattended on top of medication carts in areas accessible to residents and staff. This included opened insulin pens, pre-filled insulin syringes, and cups containing unidentified medications. In several instances, staff walked away from the medication cart, leaving medications exposed and unsecured in dining rooms and hallways. Staff interviews acknowledged that medications should not be left unattended and should be properly stored inside locked carts or storage rooms at all times. The facility's own policies require that all medications be stored securely, labeled with the date opened, and identified with the resident's name. Staff, including Certified Medication Technicians (CMTs), Registered Nurses (RNs), the Director of Nursing (DON), and the administrator, confirmed their understanding of these requirements during interviews. However, the observed practices did not align with these policies, resulting in medications being improperly labeled, stored, and left unattended during administration.
Failure to Document Ordered Treatments
Penalty
Summary
The facility failed to meet professional standards of care when staff did not document that ordered treatments were administered for three residents. The facility policy for wound care required the type of wound care, the date and time given, and any refusal with the reason to be recorded in the medical record, and staff were directed to notify the supervisor if a resident refused wound care. Resident #46 had severe cognitive impairment, was at risk for ulcers/injuries, and had a surgical wound. Physician orders directed wet-to-dry sterile dressing changes with Dakins to the left buttock twice daily, but the TARs did not contain documentation for multiple ordered treatments in September and October 2025. Resident #110 had severe cognitive impairment and pressure ulcers, including a stage 2 and a stage 4 ulcer. Orders directed daily wound treatment to the coccyx with wound cleanser, Pixie dust, calcium alginate, and border foam dressing, but the TARs lacked documentation for multiple treatments in September and October 2025. Resident #112 also had severe cognitive impairment and had orders for weekly oxygen tubing, nasal cannula, and humidifier changes, along with buttock skin treatment three times daily, but the TARs did not show documentation for several ordered care dates. RN staff stated treatments are expected to be signed off on the TAR after administration, the DON said treatments should be documented as they are done, and the administrator said staff are to document treatments on the TAR but believed the missing entries were due to staff forgetting to sign off.
Unsafe Mechanical Lift Transfers
Penalty
Summary
Facility staff failed to provide safe mechanical lift transfers for two residents when the lift legs were not used consistently as expected and the resident’s wheelchair was not positioned to avoid contact with the lift during transfer. The facility policy titled, Safe Lifting and Movement of Residents, stated staff responsible for direct resident care would be trained in the use of mechanical lifting devices and observed for competency and adherence to safe lifting procedures. One resident had severely impaired cognition and diagnoses including heart failure, neuropathy, and hemiplegia, and was dependent on staff for transfers. During an observed transfer, CNA T and NA U attached the sling and raised the resident from the wheelchair without opening the mechanical lift legs, then rolled the lift toward the bed with the legs still closed. CNA T later stated the legs should have been spread open during the transfer and said he/she had simply forgotten to do so. A second resident was cognitively intact and had diagnoses including heart failure, diabetes, anxiety disorder, depression, and spinal stenosis, and was also dependent on staff for transfers. During an observed transfer, CNA T and NA J attached the sling and raised the resident from the bed, but the staff repeatedly changed the lift leg position while trying to maneuver the resident’s larger wheelchair around the lift. The wheelchair bumped and shook the lift while the resident was suspended in the air, and the resident later said the transfer made him/her nervous. Staff interviews showed disagreement about whether the lift legs should be open or closed for the larger wheelchair, and CNA T stated he/she had not been trained or shown how to transfer the resident due to the wheelchair size.
Missing Quarterly Bed Rail Assessments
Penalty
Summary
Facility staff failed to complete quarterly bed rail assessments for six residents whose records showed bed rails were in use. The facility policy titled, "Bed Safety and Bed Rails," dated August 2022, stated bed rails are prohibited unless criteria for use have been met, including attempts to use alternatives, interdisciplinary evaluation, and resident assessment. Review of the sampled residents' records showed that quarterly side rail assessments were missing for Resident #2, #3, #10, #11, #29, and #112, despite their MDS assessments documenting bed rail use or non-use as a restraint and, in several cases, significant cognitive impairment or dependence for care. Resident #2 had severe cognitive impairment and required substantial to maximal assistance with toileting, showering, and personal hygiene; the record did not contain a quarterly side rail assessment, although the resident was observed in bed with bilateral side rails upright on two occasions. Resident #3 had severely impaired cognition and no quarterly bed rail assessment in July 2025; the resident was observed in bed with one quarter-length bed rail upright on two occasions. Resident #10 was assessed as cognitively intact, but the record did not contain quarterly bed rail assessments for May 2025 and August 2025, and the resident was observed in bed with one quarter-length bed rail upright on two occasions. Resident #11 was assessed as cognitively intact and dependent on staff for toileting, showers, and rolling in bed, yet the record did not contain a quarterly side rail assessment and the resident was observed in bed with bilateral quarter rails upright on three occasions. Resident #29 had moderate cognitive impairment and required assistance with rolling and transfers; the care plan noted quarter bed rails were used to aid repositioning and bed mobility, but no quarterly side rail assessment was present, and the resident was observed with bilateral side rails upright. Resident #112 had severe cognitive impairment and was dependent for transfers; the care plan stated bed rails were used daily as a restraint, but the record did not contain a quarterly side rail assessment, and the resident was observed in bed with bilateral side rails upright. The MDS Coordinator stated he/she was responsible for completing quarterly side rail assessments with MDS assessments, said some were not completed because he/she was busy, and was not sure whether anyone double-checked them. The RN, DON, and Administrator each stated quarterly side rail assessments were expected.
Nurse Aides Not Completed Training Within Required Time Frame
Penalty
Summary
Facility staff failed to ensure that nurse aides NA H, NA J, NA P, NA Q, and NA S completed the nurse aide training program within four months of employment. Review of the facility’s Nurse Aide Qualifications and Training Requirements policy showed that nursing assistants who do not successfully complete the required training program within the first four months of employment may be terminated or reassigned to non-nursing related services. Record review showed NA H had a hire date of 03/24/25, NA J had a hire date of 04/28/25, NA P had a hire date of 02/14/25, NA Q had a hire date of 03/12/25, and NA S had a hire date of 05/21/24, and none of their files contained documentation that they completed a nurse aide training program. During interview, NA J stated he/she had taken the classes online through the facility but had not yet taken the test and had not scheduled it because he/she was trying to study more. The Administrator stated he/she was responsible for ensuring newly hired aides completed CNA training within four months and acknowledged having aides who were outstanding on time frames. The Administrator said staff had gone through the classes but had not passed the test, and stated he/she was not aware that aides had to complete the training and be certified by four months, believing they only had to complete the education within that time frame. The DON stated the Administrator was in charge of nurse aide training and scheduling and was not sure what the required time frames were for ensuring aides had completed education and were certified.
Medication Error Rate Exceeded Allowed Threshold
Penalty
Summary
Medication administration errors exceeded the facility’s allowed rate, with 9 errors occurring in 25 observed opportunities for a 36% error rate. The facility policy required medications to be administered safely and within one hour of the prescribed time unless otherwise specified, and staff were expected to check the label three times to verify the right resident, medication, dosage, time, and route. The survey found that staff did not follow the facility’s medication timing expectations, and both late administration and wrong dosage were identified as medication errors by staff during interviews. For one resident with orders for Spironolactone, Memantine, Torsemide, Aspirin, Omeprazole, Potassium Chloride ER, Budesonide nebulizer treatments, and Arformoterol nebulizer treatments, a CMT administered the morning medications 1 hour and 24 minutes late and the breathing treatments 2 hours and 26 minutes late. For another resident with an order for two Lidocaine 5% patches daily to the lower back and hip, a CMT applied one Lidocaine 4% patch to the lower back and one Lidocaine 4% patch to the right hip, and the patches were applied 2 hours and 24 minutes after the ordered time. During interviews, staff stated that late medication administration and wrong dose were medication errors and that the nurse should be notified.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
A deficiency was identified due to the failure to ensure that a specific area within the facility was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment was not maintained in a manner that would minimize the risk of accidents, and supervision protocols were insufficient to prevent such incidents from occurring. This lack of appropriate environmental safety measures and supervision directly contributed to the deficiency cited by surveyors.
Failure to Timely Develop and Review Care Plan
Penalty
Summary
The facility failed to develop the complete care plan within 7 days of the comprehensive assessment. The care plan was not prepared, reviewed, and revised by a team of health professionals as required. This deficiency was identified based on the review of facility records and documentation, which showed that the care planning process did not meet the specified timeline and team involvement requirements.
Failure to Submit Accurate PBJ Staffing 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 for the period of July 1, 2024, through September 30, 2024. The facility's policy requires that staffing information be reported quarterly, with the deadline for the fourth fiscal quarter being November 14. However, a review of the facility's CMS PBJ Staffing Data Report dated January 2, 2025, revealed that the report for the specified period was missing. Interviews with facility staff indicated that the Human Resources (HR) department was responsible for ensuring timely submission of the PBJ report. The HR representative acknowledged awareness of the failure to file the reports on time, attributing the issue to problems with a new payroll management company. The administrator confirmed that HR was responsible for the submissions and was aware of the ongoing issues since the switch in payroll management companies, which had resulted in errors preventing correct data uploads to CMS.
Failure to Verify Medications Against MAR
Penalty
Summary
Facility staff failed to verify medications against the Medication Administration Record (MAR) for two residents, leading to a deficiency in medication administration practices. The facility's policy requires medications to be administered according to prescriber orders, with verification of the resident's identity and medication details before administration. However, observations revealed that both a Licensed Practical Nurse (LPN) and a Registered Nurse (RN) relied on cheat sheets instead of the MAR to determine insulin dosages for two residents. The LPN administered Novolin Insulin to one resident by consulting a cheat sheet posted in the medication room, while the RN used a cheat sheet on the blood glucose carrier to administer Humalog Insulin to another resident. Interviews with the staff and administration highlighted a systemic issue where cheat sheets were used to expedite the medication administration process, bypassing the MAR verification step. The LPN indicated that nursing administration was responsible for updating the cheat sheets, while the RN was unsure of the protocol if they were not present to update the sheet. The Director of Nursing (DON) and the Administrator acknowledged the use of cheat sheets but emphasized that staff should compare medications to the MAR before administration to prevent potential medication errors.
Safety and Storage Deficiencies in Resident Care
Penalty
Summary
The facility staff failed to provide safe mechanical transfers for two residents, leading to potential safety hazards. Resident #51, who was assessed with severe cognitive impairment and total dependence for transfers, was observed being transferred from bed to wheelchair by CNA F and NA G using a mechanical lift. The CNA operated the lift with the legs closed during the pivot, contrary to the facility's policy and lift operating instructions, which require the legs to be opened to the widest position for stability. Similarly, Resident #39, who was cognitively intact but also totally dependent for transfers, was transferred by CNA H and CNA I with the lift legs closed due to space constraints, which was deemed unsafe by the Director of Nursing and the administrator. The facility also failed to safely store hazardous materials in several areas, including shower rooms and storage areas. Observations revealed unlocked cabinets containing hazardous items such as aftershave, disinfectants, razors, and hand sanitizer gel in various locations accessible to residents. Interviews with staff, including CNAs and RNs, confirmed that hazardous materials should be locked away to prevent resident access and potential injury. However, staff were either unaware of the unsecured items or had forgotten to secure them, indicating a lapse in adherence to safety protocols. Additionally, the facility did not ensure medications were safely stored, as observed with medication carts left unattended with medications on top. CMT D and CMT E were responsible for the medication carts but left them unlocked and unattended, with medications accessible to residents. This practice was against the facility's policy, which mandates that medication carts be locked when not in use and medications not be left on top. The DON and administrator acknowledged the expectation for staff to keep medications secured to ensure resident safety, highlighting a failure in maintaining proper medication storage procedures.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility staff failed to maintain a medication error rate of less than five percent, resulting in a 7.32% error rate. This deficiency was observed during a survey where three medication errors occurred out of 41 opportunities, affecting two residents. Resident #45 was prescribed Memantine and Dorzolamide HCL/Timolol eye drops. During medication administration, the Certified Medication Technician (CMT) D did not attempt to re-administer a pill that the resident spit out and failed to hold the lacrimal duct after administering the eye drops, which is necessary for proper absorption. Similarly, Resident #5 was prescribed artificial tears, and CMT E also failed to hold the lacrimal duct after administering the eye drops. Both CMTs acknowledged their errors during interviews, recognizing that not holding the lacrimal duct could lead to incomplete absorption of the medication. The Director of Nursing and the Administrator confirmed that these actions were considered medication errors, as staff are expected to re-administer medications if a resident spits them out and to hold the lacrimal duct after administering eye drops.
Medication Storage and Expiration Issues in Facility
Penalty
Summary
The facility staff failed to store medications safely and effectively in two medication rooms and did not discard expired medications in one of the two medication carts. Observations revealed that the medication room at nurse's station one had an unlocked refrigerator containing opened bottles of liquid Ativan, a controlled drug, and an unlocked narcotic cabinet with opened bottles of liquid morphine. The room was left unattended with the door propped open for 10 minutes. LPN C acknowledged the oversight, stating that all medications should be kept locked unless being prepared, and narcotics should be under a double lock. In nurse's station two, the medication room also had an unlocked refrigerator containing an opened bottle of liquid Ativan and other medications, including an undated vial of TB solution and expired probiotics. Interviews with LPN B and CMT D revealed a lack of awareness and reporting regarding the absence of locks on the refrigerator, which was replaced a few months ago. Both acknowledged that narcotics should be double-locked, and the refrigerator should have a lock to prevent discrepancies. The facility's policy requires staff to check expiration dates before administering medications and to discard expired ones. However, observations showed expired medications on the medication cart at nurse's station two. Interviews with LPN B, CMT D, and LPN C confirmed that staff are responsible for checking expiration dates and removing expired medications, but due to being busy, this was not consistently done. The DON and Administrator were unaware of the lack of locks on the refrigerators and emphasized the importance of keeping narcotics double-locked and checking expiration dates to ensure resident safety.
Failure to Provide Correct Meal Portions
Penalty
Summary
The facility staff failed to provide residents with the correct portions of meals as directed by the standardized recipes, affecting all residents who received meals from the facility's kitchen. On one occasion, staff were directed to serve eight ounces of beef goulash and eight ounces of tossed salad, but observations showed that residents were served only 5.33 ounces of goulash and four ounces of salad. The evening cook did not verify the serving utensils placed by the day shift cook, leading to incorrect portion sizes being served. Additionally, a dietary aide did not check the menu for correct serving sizes due to a lack of training and was unsure where to find the correct portion sizes. On another occasion, the facility's standardized menu required four ounces of cubed potatoes to be served with breakfast, but residents received only 2.66 ounces. The dietary aide responsible for serving the meal stated that the serving utensils were sent with the meal cart, and the wrong size scoop was used. The dietary manager admitted to not keeping up with the day shift cook's training, which contributed to the staff's lack of awareness regarding correct portion sizes. This oversight in training and communication led to the failure in providing the residents with a nourishing, palatable, well-balanced diet as required.
Infection Control Lapses During Medication Administration
Penalty
Summary
Facility staff failed to adhere to infection control practices during medication administration for five residents. Certified Medication Technicians (CMTs) were observed handling medications improperly, such as picking up dropped pills with bare hands and administering them to residents. Specifically, CMT D was seen picking up an Aspirin from the medication cart with bare hands and administering it to a resident. Similarly, CMT E picked up a Vitamin D 3 pill from the cart with bare hands and administered it. Both CMTs acknowledged that gloves should be worn to prevent cross-contamination and the spread of germs. Additionally, CMT D and CMT E failed to wear gloves while administering eye drops, contrary to the facility's policy. CMT D also did not perform hand hygiene after handling medications, including during a narcotic count where pills were touched with bare hands. Interviews with the Director of Nursing and the Administrator confirmed that these actions were against the facility's infection control policies, which are designed to prevent cross-contamination and the spread of infections.
Failure to Timely Report Resident Abuse Incidents
Penalty
Summary
The facility staff failed to report two allegations of resident abuse involving three residents to the Department of Health and Senior Services (DHSS) within the required two-hour timeframe. The facility's Abuse Prohibition Policy mandates the investigation and reporting of any suspected abuse, neglect, or misappropriation of resident property. However, incidents involving Resident #1, who was assessed with severe cognitive impairment, were not reported as required. On two occasions, Resident #1 was involved in altercations with other residents, including striking Resident #3 and backhanding Resident #2, yet these incidents were not reported to DHSS in a timely manner. Additionally, an incident involving Resident #4, who was also assessed with severe cognitive impairment, was not reported within the required timeframe. Staff documented that Resident #1's hand grazed Resident #4's cheek, but there was disagreement among staff about whether the action was intentional. The facility's administrator expressed skepticism about the accuracy of staff reports, suggesting that some incidents might have been exaggerated. Despite these concerns, the facility's documentation did not show that the required notifications to DHSS were made promptly.
Failure to Investigate Allegations of Resident Abuse
Penalty
Summary
The facility staff failed to thoroughly investigate two allegations of resident abuse involving three residents. The facility's Abuse Prohibition Policy mandates the investigation of any suspected abuse, but the staff did not document investigations for incidents involving Resident #1, Resident #2, and Resident #4. Resident #1, who was assessed with severe cognitive impairment, was involved in altercations with Resident #2 and Resident #4. The facility's investigation log lacked documentation of these incidents, and the administrator was not informed of the incidents in a timely manner, leading to a lack of investigation and reporting to the Department of Health and Senior Services. In one incident, Resident #1 kicked and hit Resident #2, but there was no documentation of an investigation. In another incident, Resident #1 grazed the cheek of Resident #4, and staff had conflicting accounts of whether the action was intentional. The administrator expressed skepticism about the accuracy of staff reports and did not believe the incidents were reported correctly. Despite the facility's policy requiring all incidents to be reported to the administrator for investigation, this process was not followed, resulting in a failure to investigate and document the incidents properly.
Failure to Develop Comprehensive Care Plans Post-System Hack
Penalty
Summary
The facility failed to develop comprehensive care plans with specific interventions for four residents, all of whom were assessed with severe cognitive impairment and active diagnoses of dementia. Despite documented incidents of resident-to-resident altercations, the care plans for these residents did not include interventions or directions for staff to manage these behaviors. Interviews with staff revealed that there were no interventions in place for residents exhibiting physical and verbal behaviors, and some staff were unsure if they had access to care plans. The deficiency was exacerbated by a hacking incident that occurred in January, which resulted in the loss of all documentation, including care plans. Although the computer systems were restored by March, the facility had not updated the care plans, relying instead on care requirement sheets that did not address behavioral interventions. The care plan coordinator and the administrator acknowledged the lack of completed care plans and the absence of documented interventions for behaviors, which were expected to be included in the care plans for staff guidance.
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 63 citations issued within 25 miles in the last 12 months — including the 2 immediate-jeopardy cases — 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 Sedalia
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| E W Thompson Health & Rehabilitation Center | 0.3 mi | ★★★★★ | 2 | 0 |
| Fair View Health Care Center | 1.3 mi | ★★★★★ | 1 | 0 |
| Rest Haven Health Care Center | 2.7 mi | ★★★★★ | 4 | 1 |
| Four Seasons Living Center | 6.5 mi | ★★★★★ | 32 | 1 |
| Good Samaritan Care Center | 17.2 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.