New Madrid Living Center

In the surveyor’s words

From the most serious findings on record at New Madrid Living Center, in the surveyor’s own words.

• Actual harm, isolatedF689Apr 8, 2024

  Based on observation, interview, and record review, the facility failed to ensure the safety of one resident (Resident #1) when staff failed to follow the care plan and use proper technique during a transfer resulting in the resident entangling his/her legs together and sustaining a fractured right tibia/fibula ((tib/fib) the long bones in the lower leg). The facility census was 59. The facility did not provide a policy regarding proper transfers. 1. Record review of Resident #1's annual Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by the facility staff, dated 01/01/2024 showed: - Diagnoses of Alzheimer (a disease of the brain disorder that slowly destroys memory and thinking skills and, eventually, the ability to carry out the simplest… […]

• Actual harm, isolatedF684Sep 6, 2023

  Based on interview and record review, the facility failed to ensure staff provided the necessary care and services in accordance with professional standards of practice for one resident (Resident #1) out of three sampled residents. Staff failed to notify the physician of the resident's critical lab values in a timely manner which resulted in the resident being admitted to the hospital from 08/27/23 through 09/01/23. The facility census was 60. Review of the facility's policy titled, Lab Reporting Guidelines, dated March 2015, showed: - Once lab results are returned to the facility, the nurse will notify the physician via fax and follow-up call within 12 hours for routine labs or within one hour for stat labs; - The nurse will document on the lab report that the physician has been notified… […]

• No harm, potential for more than minimal, isolatedF578Sep 18, 2025

  Based on interview and record review, the facility failed to ensure a code status was accurately and consistently documented throughout the medical record for two residents (Residents #6 and #17) out of 14 sampled residents. The facility census was 54.Review of the facility policy titled, Advanced Directive, revised [DATE], showed: - Upon admission of a resident to the facility, the social services designee (SSD) will provide written information to the resident concerning his/her right to make decisions concerning medical care, including the right to accept or refuse medical or surgical treatment, and the right to formulate an advanced directive; - Upon admission of a resident, the SSD will inquire of the resident, and his/her family members, about the existence of any written advance… […]

• No harm, potential for more than minimal, isolatedF628Sep 18, 2025

  Based on interview and record review, the facility failed to notify the resident and the resident's representative in writing of a transfer or discharge to a hospital, including the reasons for transfer, and of the bed hold policy, including the bed hold rate at the time of the transfer, for four residents (Residents #2, #6, #10, and #21) out of five sampled residents. The facility's census was 54. Review of the facility's policy titled, Discharge/Transfer of Resident, dated March 2015, showed: - Explain transfer and reason to the resident and/or representative and give copy of signed transfer or discharge notice to the resident and/or representative or person responsible for care. […]

• No harm, potential for more than minimal, isolatedF655Sep 18, 2025

  Based on interview and record review, the facility failed to develop and implement a baseline care plan (the minimum healthcare information necessary to properly care for a resident) upon admission with specific interventions for one resident (Resident #44) out of three sampled residents. The facility census was 54.Review of facility's policy titled, Care Plan, Temporary, dated March 2015, showed:- A temporary care plan will be implemented for the resident within 24 hours of admission to assure that the resident's immediate care needs are met and maintained;- The interdisciplinary care plan team and/or admitting nurse will review the physician orders and implement a nursing care plan to meet the immediate care needs of the resident. […]