Above average — CMS composite of the measures below.
The next survey window likely opens around December 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 Delta South Nursing & Rehabilitation during CMS and state inspections, most recent first.
Failure to Document and Honor Resident Food Preferences: The facility did not consistently assess, document, or communicate residents’ food likes and dislikes in care plans or dietary cards. Multiple residents reported that staff never asked about their preferences, some said disliked foods were still served, and several were unaware of available substitutions. A resident alternative foods list was kept in the DM’s office but was not posted for residents to view.
Delayed Transmission of MDS Assessments: The facility failed to transmit MDS assessments in a timely manner for six residents. Quarterly MDSs were completed but not submitted for several weeks, and staff interviews showed the MDS Coordinator sometimes waited to send a batch of assessments and sometimes forgot to submit them. The DON, ADON, SSD, and Administrator all stated assessments should be reviewed and submitted promptly.
Failure to Complete Baseline Care Plans Within 48 Hours: The facility failed to develop and implement baseline care plans for two residents within 48 hours of admission. Records showed no documentation of a baseline care plan for either resident, and interviews confirmed the charge nurse was expected to initiate the plan upon admission and ensure care areas were addressed in a timely manner.
Missed Restorative Nursing Services for Residents With Limited ROM: Four residents with significant mobility impairments, including stroke, paraplegia, bilateral AKA, and other conditions, had restorative plans for ROM, strengthening, transfers, and mobility exercises, but records showed repeated missed restorative opportunities across multiple months. Residents reported not receiving services regularly, and the RNA stated he/she was pulled to the floor at times and believed ADLs counted as restorative exercises, while leadership stated residents should receive the therapy-based services outlined in the plans.
A facility failed to reconcile controlled substance counts for multiple residents receiving alprazolam, tramadol, and Ativan. MARs showed doses had been given, but the CMT narcotic count log and cart observations showed one-tablet discrepancies for each affected resident. The CMT said meds were not charted right away because he/she got busy, and the DON and Administrator stated controlled meds should be charted immediately and the count log should always match the medication on hand.
A facility failed to consistently document a resident's code status, resulting in conflicting information in the medical records. The resident's face sheet and Physician's Order Sheet indicated a full code status, while a DNR form and a red dot on the chart suggested otherwise. Interviews with staff revealed confusion about the resident's actual code status, and the resident confirmed a preference for full code. The Administrator expected accurate documentation throughout the medical record.
The facility failed to maintain a safe, clean, and homelike environment, with issues such as an unhung shower curtain, stained floors, and damaged sheetrock observed. Interviews revealed inadequate communication and documentation of environmental concerns among staff.
The facility failed to submit quarterly MDS assessments on time for four residents, with delays ranging from 33 to 49 days. Staff interviews revealed a lack of knowledge and responsibility regarding the MDS submission process, contributing to the failure to meet federal guidelines.
A facility failed to follow procedures for documenting and disposing of a controlled medication for a resident. The resident's lorazepam, prescribed for terminal restlessness and shortness of breath, was found in the medication room without proper documentation in the narcotic count book. Interviews revealed that staff did not follow the facility's policy for controlled substances, leading to a lack of proper management and documentation of the medication.
The facility failed to ensure appropriate diagnoses and monitoring for psychotropic medications for two residents. One resident was prescribed risperidone without documented behaviors or monitoring, while another was on multiple psychotropic medications without appropriate diagnoses or behavior documentation. Interviews revealed a lack of understanding and documentation regarding the necessity and monitoring of these medications.
The facility had a medication error rate of 13.33%, affecting two residents. A CMT administered an antibiotic not prescribed to a resident and failed to give the prescribed eye drops and nasal spray. Another resident did not receive their prescribed medication due to it being unavailable, and the CMT did not inform the charge nurse. The DON and Administrator expected accurate medication administration and documentation.
The facility failed to maintain sanitary conditions in food storage and distribution, risking cross-contamination and food-borne illness for all residents. Observations showed improper food storage with unlabeled and undated items in the freezer and refrigerator, and unsanitary conditions in the dishwashing room and kitchen equipment. Staff interviews revealed a lack of adherence to cleaning schedules and proper food handling practices.
The facility failed to provide proper incontinent care for two residents and missed scheduled showers for another. One resident did not receive complete peri care, while another was not consistently asked or documented for showers, citing staffing issues. The care plans lacked specific guidance, leading to deficiencies in care.
The facility failed to follow hand hygiene and glove-changing protocols during incontinent care for three residents. CNAs did not change gloves or perform hand hygiene at critical points, such as after cleaning soiled areas and before applying clean briefs. Interviews revealed that staff were aware of the proper procedures but failed to adhere to them due to nervousness or oversight. The facility's policy requires strict adherence to hand hygiene to prevent the spread of infections.
Failure to Document and Honor Resident Food Preferences
Penalty
Summary
The facility failed to create an environment respectful of each resident’s right to make choices about food preferences and dislikes. Based on interviews and record review, the facility did not consistently assess, document, or communicate residents’ food likes and dislikes in the care plan or dietary card, and residents reported that staff had not asked them about food preferences since admission. The deficiency affected two residents in the sample and eight additional residents outside the sample, with the facility census at 48. Resident #2 had diagnoses including type II DM, heart failure, UTI, and depression. The resident’s care plan addressed independence and a dietary consult, but did not address diet, food likes, or dislikes. The dietary card also had no documentation of food likes or dislikes. During interview, the resident said he/she did not like pulled pork and potato salad but still received them at meals, would prefer a sandwich or cup of soup at lunch, and stated staff had never asked about food dislikes since admission and were not aware of an alternative list of food choices. Resident #14 had diagnoses of stroke, hypertension, anxiety, and depression. The care plan did not address diet, food likes, or dislikes, and the dietary card had no documentation of likes or dislikes. The resident stated staff had never asked what his/her dislikes were and did not know how kitchen staff were aware of them. Similar findings were identified for Residents #18, #21, #33, #42, #43, #44, #50, and #51, whose records also lacked documentation of food preferences and whose interviews showed they had not been asked about dislikes or were unaware of available substitutions. Observations showed a Resident Alternative Foods and/or Substitutions Always Available list in the DM’s office, but it was not posted for residents to view. The DM, ADON, DON, and Administrator each stated they would expect residents’ likes and dislikes to be included on the dietary card and updated as needed, and that residents should be informed of alternative foods and substitutions.
Delayed Transmission of MDS Assessments
Penalty
Summary
The facility failed to electronically transmit MDS assessments to the State within 7 days of assessment for six sampled residents. Review of the MDS records showed that quarterly assessments for Residents #6, #7, #14, #16, and #22 were completed in late November 2025 but were not accepted/transmitted until 01/07/26, with delays ranging from 39 to 41 days. Resident #45’s quarterly MDS was completed on 12/18/25 and not accepted/transmitted until 01/13/26, 26 days late. The facility’s policy required all MDS assessments to be completed, encoded, and transmitted in accordance with OBRA regulations, and identified the MDS Coordinator as responsible for ensuring edits were made and transmission reports maintained. During interviews, the SSD, ADON, DON, and Administrator stated that assessments should be reviewed for accuracy and submitted in a timely manner, with the MDS Coordinator responsible for submission. The MDS Coordinator stated that assessments were sometimes held until a batch was ready, that he/she sometimes forgot to submit them, and that assessments should be submitted within 14 days of completion.
Failure to Complete Baseline Care Plans Within 48 Hours
Penalty
Summary
The facility failed to develop and implement a baseline care plan for two residents, both admitted on 01/02/26, within 48 hours of admission. Review of the medical records for both residents showed no documentation of a baseline care plan, and the facility did not complete the baseline care plan within the required timeframe. The facility policy titled, Care Plans - Baseline, stated that a baseline plan of care is to be developed for each resident within 48 hours of admission and must include the minimum healthcare information necessary to properly care for the resident. During interviews, the ADON stated that a resident should have a baseline care plan completed upon admission and within 48 hours, with care areas addressed, and that the charge nurse should start it and complete it if able, or the oncoming charge nurse should follow up. The DON stated she expected the baseline care plan to be completed within 48 hours so proper care could be given, but said these two residents' baseline care plans were not completed in a timely manner because both admissions were on a Friday and she thought there would be enough time to finish them on Monday. The Administrator stated she expected the baseline care plan to be completed within 48 hours with care areas addressed and that the charge nurse should initiate it upon admission with follow-up to ensure timely completion.
Missed Restorative Nursing Services for Residents With Limited ROM
Penalty
Summary
The facility failed to ensure residents with limited ROM received appropriate treatment and services to increase ROM and/or prevent further decrease in ROM for four sampled residents with mobility limitations. The deficiency was based on interview and record review showing that restorative nursing services were not provided as planned for residents with diagnoses including femur fracture, CHF, shoulder dislocation, dementia, paraplegia, edema, osteoporosis, PVD, depression, kidney failure, bilateral above-the-knee amputation, atrial fibrillation, stroke, gait and mobility abnormalities, muscle weakness, osteoarthritis, hemiplegia, and abnormal posture. Resident #3 had a restorative nursing plan that included ROM, bed mobility/walking, transfers, dressing, grooming, and toileting three times weekly, with interventions such as lower extremity strengthening, standing balance/tolerance, and transfers. The record showed missed restorative opportunities for every scheduled occurrence reviewed: 12 of 12 missed in November 2025, 12 of 12 missed in December 2025, and 6 of 6 missed in January 2026. Resident #6 had a restorative plan for ROM and transfer training three times weekly, with exercises including bilateral lower extremity strengthening, sit-to-stand, parallel bars, seated forward leans, and seated reaching activities. The documentation showed 12 of 12 missed opportunities in November 2025, 12 of 14 missed in December 2025, and 5 of 6 missed in January 2026. Resident #7 had a restorative plan for ROM, bed mobility/walking, transfers, dressing, grooming, and toileting three times weekly, with interventions including seated reaching, upper extremity bike, wheelchair propulsion, postural exercises, scapula squeezes, shoulder rolls, and shoulder shrugs. The documentation showed 12 of 12 missed opportunities in November 2025, 12 of 12 missed in December 2025, and 6 of 6 missed in January 2026. Resident #45 had a restorative plan for ROM, bed mobility/walking, and transfers three times weekly, with interventions including sit-to-stands, Nu-step, lower extremity strengthening, left-sided stretches, and ROM. The documentation showed 12 of 12 missed opportunities in November 2025, 12 of 12 missed in December 2025, and 6 of 6 missed in January 2026. Interviews supported that the restorative services were not being carried out as planned. One resident stated restorative services were not received regularly and that only stretching was sometimes provided. Another resident said restorative services were not received weekly and that the first recent restorative session occurred after a long gap. The RNA stated there were weeks when he/she was pulled to the floor and missed restorative services, and he/she believed ADLs counted as restorative exercises. The Rehab Director, ADON, DON, and Administrator each stated residents should receive the restorative services outlined in the therapy recommendations, and the RNA should document services, refusals, and notify nursing when services could not be provided.
Controlled Substance Counts Did Not Reconcile for Multiple Residents
Penalty
Summary
The facility failed to reconcile controlled substances for seven of 13 sampled residents, including residents receiving alprazolam, tramadol, and Ativan. The facility’s policy stated that controlled substance inventory is monitored and reconciled to identify loss or potential diversion and that reconciliation includes records of access and usage, MARs, declining inventory records, and destruction, waste, and return-to-pharmacy records. For each of the seven residents, the MAR showed a controlled medication dose had been administered earlier in the day, but the CMT narcotic count log and direct observation of the medication cart showed a one-tablet discrepancy between the documented count and the tablets actually present for each resident’s medication card. The affected residents included one resident with an alprazolam order for anxiety, several residents with tramadol orders for pain, and another resident with an Ativan order for anxiety. During interview, the CMT stated medications were supposed to be signed off as soon as they were given but had not been charted yet because he/she got busy. The DON stated the CMT should chart medications as soon as they were given and that the residents’ medication count log should always reconcile with the correct number of medications in the facility. The Administrator stated nursing staff should chart immediately after giving a controlled scheduled or PRN medication.
Inconsistent Documentation of Code Status for a Resident
Penalty
Summary
The facility failed to consistently document the code status for a resident, leading to a discrepancy in the resident's medical records. The resident's face sheet and Physician's Order Sheet indicated a full code status, while a DNR form signed by the resident and physician was also present in the chart. Additionally, a red dot on the resident's hard chart indicated a DNR status, conflicting with the green dot system used by the facility to denote a full code status. Interviews with the Medical Records Staff, Director of Nursing, and Social Services Director revealed confusion and lack of clarity regarding the resident's actual code status. The Social Services Director recalled discussing the code status with the resident and a family member at the time of admission, confirming the resident was considered a full code. However, the presence of a DNR form in the resident's chart, which the Social Services Director could not account for, contributed to the inconsistency. The resident expressed a desire to be a full code during an interview, further highlighting the documentation error. The facility's Administrator acknowledged the expectation for accurate and consistent documentation of code status throughout the resident's medical record.
Failure to Maintain a Homelike Environment
Penalty
Summary
The facility failed to provide a safe, clean, and comfortable homelike environment, which had the potential to affect all residents. Observations over several days revealed multiple environmental deficiencies. An unhung shower curtain was repeatedly observed on a shower chair in a shower area, and several small dried dark areas were noted on the floor in front of a decorative table and recliner. Additionally, a large hole and missing sheetrock were observed on a resident closet door, and six medium-sized stuffed animals were placed on top of an over-the-bed light. A ceiling tile with a large brown stain was also noted. Interviews with housekeeping staff and the Maintenance Supervisor revealed a lack of effective communication and documentation regarding environmental issues. Housekeepers indicated they would inform the Maintenance Supervisor of any needed repairs, but neither had observed any issues during their rounds. The Maintenance Supervisor relied on staff to report issues but noted that a maintenance log was no longer in use. The Administrator expected department heads to address environmental concerns during morning meetings and for housekeeping to document issues, but this was not occurring effectively.
Failure to Timely Submit MDS Assessments
Penalty
Summary
The facility failed to electronically transmit quarterly Minimum Data Set (MDS) assessments in a timely manner for four residents, as required by federal guidelines. The facility's policy mandates that resident assessments be conducted and submitted according to federal and state timeframes, with the assessment coordinator or designee responsible for ensuring compliance. However, the facility did not adhere to these guidelines, resulting in delayed submissions for Residents #7, #19, #28, and #35, with delays ranging from 33 to 49 days past the required submission period. Interviews with facility staff revealed a lack of knowledge and responsibility regarding the MDS submission process. The Social Service Director, who is a Licensed Practical Nurse, indicated that they completed parts of the MDS, while a Registered Nurse was responsible for reviewing, completing, and submitting them. The Administrator admitted to having limited knowledge about the MDS process, and the Director of Nursing stated he was unaware of the submission requirements. This lack of awareness and coordination among staff contributed to the failure to meet the mandated submission deadlines.
Failure to Document and Dispose of Controlled Medication
Penalty
Summary
The facility failed to implement procedures to ensure medications were accurately administered, documented, disposed of, and reconciled for a resident. The facility's policy on controlled substances requires that controlled substance inventory be monitored and reconciled to identify loss or potential diversion, with nursing staff counting controlled medication inventory at the end of each shift. However, for one resident, there was no individual controlled substance record for lorazepam, a controlled medication prescribed for terminal restlessness and shortness of breath. The medication was found in the locked refrigerator with no documentation of administration in the narcotic count book. Interviews with staff revealed that the required documentation and procedures were not followed. An LPN acknowledged that there should have been dates and signatures in the narcotic count book for the administered doses. The DON was unsure why the doses were not documented and why the medication had not been brought for destruction. The Administrator stated that the medication should have been removed and destroyed by two nurses, but was unsure why it remained in the facility. This lack of adherence to policy resulted in a failure to properly manage and document the controlled medication for the resident.
Inadequate Monitoring and Documentation for Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure appropriate diagnoses and monitoring for the use of psychotropic medications for two residents. Resident #2, diagnosed with Alzheimer's and severe dementia with agitation, was prescribed risperidone without documentation of an appropriate diagnosis or specific behaviors warranting its use. Additionally, there was no monitoring of behaviors related to the medication. Similarly, Resident #14, with diagnoses of major depressive disorder with psychotic features and Alzheimer's, was prescribed Abilify, sertraline, and mirtazapine without documentation of appropriate diagnoses or specific behaviors for the use of these medications. Interviews with facility staff revealed a lack of understanding and documentation regarding the necessity and monitoring of psychotropic medications. The Certified Medication Technician was unsure of the reason for Resident #2's risperidone prescription, and the Director of Nursing acknowledged the absence of a monitoring process for residents on psychotropic medications. The Administrator also expected appropriate diagnoses and monitoring systems to be in place but found them lacking. The facility's policies emphasized the need for non-pharmacological interventions and proper documentation, which were not adhered to in these cases.
Medication Administration Errors and Documentation Issues
Penalty
Summary
The facility failed to maintain a medication error rate of less than five percent, resulting in a 13.33% error rate during the survey. This deficiency affected two residents out of six sampled, with the potential to impact all residents in the facility. For Resident #10, the Certified Medication Technician (CMT) mistakenly administered Macrobid, an antibiotic that was no longer prescribed, and failed to administer the prescribed Refresh Plus eye drops and Flonase nasal spray. The resident confirmed that they were not on the antibiotic anymore and usually received the eye drops and nasal spray with their morning medications. The CMT admitted to being nervous and administering the wrong medication. For Resident #45, the CMT did not administer the prescribed Prevagen medication because it was not available in the medication cart, and the CMT failed to notify the charge nurse about the missing medication. The Licensed Practical Nurse (LPN) was unaware of any missing medications, indicating a breakdown in communication. The Director of Nursing (DON) and the Administrator both expressed expectations that staff should administer medications as ordered and accurately document medication administration.
Sanitation and Food Storage Deficiencies
Penalty
Summary
The facility failed to store and distribute food under sanitary conditions, which increased the risk of cross-contamination and food-borne illness for all 53 residents. Observations revealed multiple instances of improper food storage, including opened and undated food items in the walk-in freezer and standup refrigerator. Specifically, there were exposed and undated frozen catfish, dinner rolls, hushpuppies, and corn dogs in the freezer, as well as unlabeled and undated sponge cakes, a chocolate dessert, and a half-eaten sundae in the refrigerator. These practices were contrary to the facility's policy, which required all foods to be covered, labeled, dated, and stored properly. Additionally, the dishwashing room and kitchen equipment were found to be in unsanitary conditions. The dishwashing room had an empty paper towel and soap dispenser, cluttered storage, and a buildup of dirt and debris on various surfaces. Kitchen equipment, including the plate warmer cart, stove/oven, and double-fryer, had a buildup of grime and grease. Interviews with kitchen staff and the Dietary Manager revealed a lack of adherence to cleaning schedules and expectations for maintaining cleanliness and organization. The Administrator also expressed expectations for daily cleaning and proper labeling and storage of food items, which were not met.
Deficiencies in Incontinent Care and Shower Scheduling
Penalty
Summary
The facility failed to provide proper incontinent care for two residents and scheduled showers for another resident, leading to deficiencies in the care provided. Resident #1, who was always incontinent of bowel and bladder and required assistance for toileting and personal hygiene, did not receive complete incontinent care. During an observation, a CNA cleaned the resident's front peri area and left side but failed to clean the right hip and buttock. The CNA later admitted to being nervous and acknowledged not providing appropriate care. Resident #19, also always incontinent of bowel and bladder and requiring maximum assistance, did not receive complete peri care. During an observation, a CNA cleaned the resident's rectal area, buttocks, and hips but failed to clean the front peri area. The CNA confirmed the correct procedure was to clean from front to back, indicating a lapse in following proper care protocols. Resident #37, with multiple medical conditions including congestive heart failure and acute kidney failure, did not receive scheduled showers consistently. The resident's care plan did not specify shower frequency or assistance required, and records showed five missed showers out of ten scheduled opportunities. Interviews revealed that the resident was sometimes not asked if they wanted a shower, and staffing issues were cited as a reason for missed showers. Documentation of showers and refusals was also lacking, as confirmed by multiple staff members, including the ADON and DON.
Failure to Adhere to Hand Hygiene and Glove-Changing Protocols
Penalty
Summary
The facility failed to adhere to its hand hygiene and glove-changing protocols during the provision of incontinent care for three residents. Observations revealed that Certified Nursing Assistants (CNAs) did not change gloves or perform hand hygiene at critical points during care. For Resident #1, CNA D did not change gloves or perform hand hygiene after cleaning the resident's front peri area, before removing a urine-soaked brief, or before touching the peri wash bottle and cleaning the rectal area. Similarly, CNA M, while caring for Resident #19, did not change gloves or perform hand hygiene after cleaning fecal material and before applying barrier cream and placing a clean brief. CNA C, caring for Resident #251, failed to perform hand hygiene before starting care and did not change gloves before applying a new brief. Interviews with the CNAs involved indicated awareness of the proper procedures, with admissions of nervousness and acknowledgment of mistakes. The Director of Nursing and the Administrator both confirmed the expectation that staff should change gloves between dirty and clean tasks and perform hand hygiene as per the facility's policy. The facility's policy emphasizes hand hygiene as the primary means to prevent the spread of healthcare-associated infections, requiring staff to perform hand hygiene before and after resident contact, after glove removal, and when moving from soiled to clean tasks.
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Illustrative
What surveyors actually found near you
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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.
Illustrative
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Illustrative
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Nursing homes near Sikeston
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 | 1.4 mi | — | 0 | 0 |
| Sikeston Convalescent Center | 1.7 mi | ★★★★★ | 9 | 0 |
| Hunter Acres Caring Center | 2.2 mi | ★★★★★ | 0 | 0 |
| Clearview Nursing Center | 2.5 mi | ★★★★★ | 14 | 0 |
| Bertrand Nursing And Rehab Center | 6.6 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.