Cycle 1
Health 2025-11-17 · Fire 2025-11-17
4 health deficiencies
Top issue: Administration (1 deficiency)
1 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Fredericktown, MO
Madison Medical Center
5-star overall rating with 4-star inspections with 4 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
611 West Main Street, Fredericktown, MO
(573) 783-3341
Overall
5 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
99
Certified beds
Average residents
60
Average occupied residents
Ownership
Government
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2024-10-01
CMS approved date
Coverage
Medicaid
Participation flags
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Hospital-based
Yes
CMS reports the provider resides in a hospital
Staffing
Hours and turnover
RN hours / resident day
0.52
Registered nurse staffing · state 0.46 · national 0.68
LPN hours / resident day
0.61
Licensed practical nurse staffing · state 0.68 · national 0.87
Aide hours / resident day
2.84
Nurse aide staffing · state 2.33 · national 2.35
Total nurse hours
3.98
All reported nurse hours · state 3.47 · national 3.89
Licensed hours
1.14
RN + LPN hours · state 1.14 · national 1.54
Weekend hours
3.35
Weekend nurse staffing · state 3.04 · national 3.43
Weekend RN hours
0.30
Weekend registered nurse coverage · state 0.33 · national 0.47
Physical therapist
0.00
Reported PT staffing · state 0.05 · national 0.07
Adjusted RN hours
0.66
CMS adjusted RN staffing hours
Adjusted total hours
5.04
CMS adjusted total nurse staffing hours
Case-mix index
1.08
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
0%
Annual nurse turnover
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | Not Available |
10.72%
|
Not Available · Eligible stays Not Available · Observed rate Not Available · Lower 95% interval Not Available · This provider is not required to submit SNF QRP data. |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays Not Available · Observed rate Not Available · Lower 95% interval Not Available · This provider is not required to submit SNF QRP data. |
| Medicare spending per beneficiary | Not Available |
1.02
|
This provider is not required to submit SNF QRP data. |
| Drug regimen review with follow-up | Not Available |
95.27%
|
Numerator Not Available · Denominator Not Available · This provider is not required to submit SNF QRP data. |
| Falls with major injury | Not Available |
0.77%
|
Numerator Not Available · Denominator Not Available · This provider is not required to submit SNF QRP data. |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator Not Available · This provider is not required to submit SNF QRP data. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator Not Available · This provider is not required to submit SNF QRP data. |
| Pressure ulcers or injuries, new or worsened | Not Available |
2.29%
|
Numerator Not Available · Denominator Not Available · Adjusted rate Not Available · This provider is not required to submit SNF QRP data. |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays Not Available · Observed rate Not Available · Lower 95% interval Not Available · This provider is not required to submit SNF QRP data. |
| Staff COVID-19 vaccination coverage | Not Available |
8.2%
|
Numerator Not Available · Denominator Not Available · This provider is not required to submit SNF QRP data. |
| Staff flu vaccination coverage | Not Available |
42%
|
Numerator Not Available · Denominator Not Available · This provider is not required to submit SNF QRP data. |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator Not Available · This provider is not required to submit SNF QRP data. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator Not Available · This provider is not required to submit SNF QRP data. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator Not Available · This provider is not required to submit SNF QRP data. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator Not Available · This provider is not required to submit SNF QRP data. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
84.8%
15.2 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
90.9%
9.1 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.7% |
4.1%
1.4 pts better
|
3.3%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.9% · Q3 3.3% · Q4 5.2% · 4Q avg 2.7% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
14.7%
14.7 pts better
|
11.4%
11.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents who lose too much weight | 4.5% |
5.5%
1 pts better
|
5.4%
0.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.3% · Q2 7.0% · Q3 2.2% · Q4 6.4% · 4Q avg 4.5% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 26.8% |
25.3%
1.5 pts worse
|
19.6%
7.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.6% · Q2 30.2% · Q3 26.7% · Q4 25.0% · 4Q avg 26.8% |
| Percentage of long-stay residents who received an antipsychotic medication | 15.7% |
25.0%
9.3 pts better
|
16.7%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.0% · Q2 19.4% · Q3 17.1% · Q4 13.2% · 4Q avg 15.7% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.0%
About the same
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 3.5% |
20.3%
16.8 pts better
|
16.3%
12.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q3 4.6% · 4Q avg 3.5% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 8.5% |
19.8%
11.3 pts better
|
14.9%
6.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q2 5.0% · Q3 9.5% · Q4 11.4% · 4Q avg 8.5% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 2.1% |
1.4%
0.7 pts worse
|
1.0%
1.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 3.0% · Q3 3.1% · Q4 2.3% · 4Q avg 2.1% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.3% |
2.6%
0.3 pts better
|
1.7%
0.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.8% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 2.3% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 19.7% |
18.1%
1.6 pts worse
|
19.8%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q2 27.1% · Q3 22.7% · Q4 10.7% · 4Q avg 19.7% |
| Percentage of long-stay residents with pressure ulcers | 4.4% |
5.0%
0.6 pts better
|
5.1%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.4% · Q2 5.2% · Q3 5.5% · Q4 5.2% · 4Q avg 4.4% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 80.2% |
66.4%
13.8 pts better
|
81.7%
1.5 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q2 76.9% · Q3 81.8% · 4Q avg 80.2% |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
2.2%
2.2 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 92.6% |
63.5%
29.1 pts better
|
79.7%
12.9 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 92.6% |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-09-13 · Fire 2024-09-13
1 health deficiencies
Top issue: Infection Control (1 deficiency)
1 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-11-17
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-12-03
F · Potential for more than minimal harm
2024-09-13
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-10-25
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-11-17
F868 · Administration Deficiencies
Health
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Corrected 2025-12-03
E · Potential for more than minimal harm
2025-11-17
F628 · Resident Rights Deficiencies
Health
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Corrected 2025-12-03
D · Potential for more than minimal harm
2025-11-17
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2025-12-03
D · Potential for more than minimal harm
2025-11-17
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-12-03
D · Potential for more than minimal harm
2024-09-13
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-10-25
Penalties and ownership
What sits behind the stars
Ownership
Nearby options
Other facilities in reach
#1
Claru Deville Nursing Center
Fredericktown, MO
2-star overall rating with 1-star inspections with abuse icon flag with $94,613 in total fines with 11 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#2
St Francois Manor
Farmington, MO
4-star overall rating with 4-star inspections with 9 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#3
Baptist Homes Of Arcadia Valley
Ironton, MO
2-star overall rating with 3-star inspections with 8 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
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