Average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Independence Care Center Of Perry County during CMS and state inspections, most recent first.
Late Transmission of MDS Assessments: The facility failed to transmit multiple MDS assessments within the required 14-day timeframe for several residents. Late quarterly, annual, and significant change assessments were identified, with delays ranging from 1 to 36 days, and the Administrator and MDS Coordinator acknowledged the expected RAI Manual timeframes.
Two residents had quarterly MDS assessments that were not completed within the required OBRA timeframe. One resident had an annual MDS followed by an incomplete, unsubmitted quarterly MDS, and another resident had a significant change MDS followed by an incomplete, unsubmitted quarterly MDS. The Administrator and MDS Coordinator stated MDS assessments were expected to be completed per RAI Manual timeframes.
MDS assessments were coded inaccurately for multiple residents. Several residents with side rail, grab bar, or enabler bar assessments showing the devices were used to support independence with bed mobility were instead coded in P0100 as daily use of bed rails or side rails as a physical restraint. In another case, an annual MDS failed to capture a documented GDR for Seroquel after the dose was reduced from BID to HS.
Staff failed to follow infection control practices during meal service by touching residents’ food, cups, straws, utensils, and hands with bare hands and by not performing hand hygiene between resident tasks. During meal observations, NAs and CNAs handled the drinking ends of straws, opened food items with bare fingers, moved plates and cups, and assisted multiple residents with eating without washing or sanitizing hands. Staff and leadership stated that hand hygiene was expected before serving residents, between residents, and after touching food or resident items.
A CMT and an LPN failed to follow infection control practices during medication administration and blood sugar care for multiple residents. The CMT administered eye drops without gloves, handled medications with ungloved hands, and used the same tissue to blot both eyes after eye drop administration. The LPN did not sanitize hands before or after finger stick blood sugar checks and insulin administration, and also failed to sanitize hands after glove removal between resident care tasks.
Failure to Perform Regular Bed Rail and Entrapment Inspections: Staff did not complete regular inspections of bed frames, mattresses, side rails, and enabler bars for three residents. One resident's side rail inspection occurred months after installation, another's occurred more than a year later, and one resident had no inspection documented. The Administrator, MDS Coordinator, and Maintenance staff gave conflicting accounts, and Maintenance stated it did not perform routine bed rail inspections or entrapment assessments.
The facility failed to assess and document the use of position change alarms for five residents, potentially classifying them as restraints. These alarms were used without obtaining a physician's order or conducting an assessment. Residents with conditions like Alzheimer's, dementia, and Parkinson's had alarms in place without proper documentation. Interviews revealed a lack of expectation for orders or assessments, relying on nurses' discretion.
The facility failed to provide written notifications to residents and/or their representatives for hospital transfers, affecting six residents. Despite the policy requiring written notice before transfers, the facility did not maintain documentation to confirm notices were sent. Interviews revealed that the facility mailed a combined Transfer Notice and bed hold information form but did not keep copies, leading to this deficiency.
The facility failed to provide written information about the bed hold policy to residents and their representatives during hospital transfers, as required by their policy. This deficiency was identified for seven residents, with no documentation in their medical records to confirm that the policy was communicated at the time of transfer. Interviews revealed that the facility mailed a Transfer Notice form but did not retain copies or require signatures for receipt confirmation.
A resident with multiple diagnoses, including Guillain-Barre Syndrome, was transferred without a gait belt by two CNAs, contrary to facility policy. The CNAs believed it was safe to transfer without a gait belt if two staff were present. Interviews with the DON and an LPN indicated an expectation for proper transfer techniques.
The facility failed to assess and document the risks and benefits of bed rail use for six residents, leading to a deficiency in safety protocols. Residents with cognitive and physical impairments were using bed rails without documented assessments or informed consent. Interviews confirmed the lack of a formal process for evaluating bed rail use.
The facility failed to adhere to infection control practices during wound and catheter care for two residents and while passing meal trays. Staff did not wear gowns as required by Enhanced Barrier Precautions and failed to perform hand hygiene after touching soiled surfaces. Misunderstandings about the need for precautions were evident among staff.
The facility failed to conduct regular inspections of bed frames, mattresses, and side rails for several residents, with no documentation of maintenance assessments. Observations showed residents in beds with various side rail configurations, but no evidence of regular checks for entrapment risks. Interviews revealed inconsistencies in maintenance practices, with no documentation of regular inspections despite expectations from the Administrator.
Late Transmission of MDS Assessments
Penalty
Summary
The facility failed to electronically transmit MDS assessments within the required timeframe for multiple residents. Review of records showed late transmission of annual, quarterly, and significant change MDS assessments for Resident #1, Resident #2, Resident #3, Resident #8, Resident #33, and Resident #36. The delays ranged from 1 day late to 36 days late, and included assessments with care plan completion dates that were not transmitted and accepted within 14 days as required by the RAI Manual. The facility census was 76, and 6 residents were identified with late transmissions, including 5 residents from the sampled group and 1 resident outside the sample. The facility policy stated that MDS assessments are to be completed and transmitted in accordance with CMS regulations and scheduled according to required timeframes. During interview on 01/09/26, the Administrator and MDS Coordinator stated they would expect MDS assessments to be completed per the RAI Manual timeframes. The report documented that the facility did not ensure timely electronic submission of the assessments reviewed for these residents.
Failure to Complete Quarterly MDS Assessments on Time
Penalty
Summary
The facility failed to complete quarterly MDS assessments within the required 92-day timeframe for two residents, Resident #3 and Resident #33, out of 18 sampled residents. The facility census was 76. The report states that the facility’s policy required timely and compliant completion and transmission of MDS assessments, and the RAI Manual required the next non-comprehensive assessment to be due within 92 days after the ARD of the most recent OBRA assessment. For Resident #3, the record showed an annual MDS with an ARD of 08/20/25 and completion on 09/03/25, followed by a quarterly MDS dated 11/20/25 that was incomplete and unsubmitted. For Resident #33, the record showed a significant change MDS with an ARD of 09/05/25 and completion on 09/16/25, followed by a quarterly MDS dated [DATE] that was incomplete and unsubmitted. During interview on 01/09/26 at 4:05 P.M., the Administrator and MDS Coordinator stated they would expect MDS assessments to be completed per the RAI Manual timeframes.
MDS assessments were coded inaccurately for bed rail use and one antipsychotic GDR
Penalty
Summary
The facility failed to document accurate MDS assessments for eight sampled residents and one resident outside the sample. In multiple records, the facility coded Section P0100, Physical Restraints, as daily use of bed rails or side rails even though the residents’ side rail assessments described the devices as grab bars, enabler bars, or side rails used to keep the resident as independent as possible with bed mobility. The Administrator stated there were no restraints in the building besides side rails and half rails, but felt none of those were restraints. The Administrator and MDS Coordinator later stated they would expect the MDS assessments to be coded accurately. Resident #1 had diagnoses including muscle weakness, unsteadiness on feet, history of falling, difficulty walking, and low back pain. A side rail assessment documented use of one side rail to support independence with bed mobility, and observation showed one half rail on the right side and one grab bar on the left side of the bed in upright positions. However, the quarterly MDS dated 11/25/25 coded daily use of bed rails in Section P0100 as a physical restraint. Resident #2 had diagnoses including muscle weakness, repeated falls, Alzheimer's dementia, and hemiplegia. A side rail assessment documented use of one side rail to support independence with bed mobility, and observations showed a left side half rail in the upright position. The significant change MDS dated 10/01/25 also coded daily use of bed rails as a physical restraint. Resident #4 had diagnoses including muscle weakness, need for assistance with personal care, lack of coordination, left humerus fracture, and left femur fracture. The side rail assessment stated side rails/grab bar were a medical necessity due to fractures and to improve bed mobility, and observations showed an enabler bar on the right side of the bed in the upright position. The admission MDS dated 11/09/25 coded daily use of bed rails as a physical restraint. Resident #5 had diagnoses including muscle weakness, difficulty walking, unsteadiness on feet, and gait abnormalities; the side rail assessment documented one side rail to keep the resident as independent as possible with bed mobility, while the quarterly MDS dated 11/25/25 coded daily use of bed rails as a physical restraint. Resident #6 had diagnoses including pain, muscle weakness, difficulty walking, unsteadiness on feet, and lack of coordination; the side rail assessment documented one grab assist bar to keep the resident as independent as possible with bed mobility, but the quarterly MDS dated 11/07/25 coded daily use of bed rails as a physical restraint. Resident #25 had diagnoses including CHF, muscle weakness, and low back pain. The side rail assessment documented a grab assist bar to keep the resident as independent as possible with bed mobility, and observation showed the grab bar raised on the left side of the bed. The quarterly MDS dated 10/15/25 coded daily use of side rails as a physical restraint. Resident #33 had diagnoses including COPD, muscle weakness, and lack of coordination; the side rail assessment documented a grab assist bar in place to keep the resident as independent as possible with bed mobility and transfers, but both the quarterly MDS dated 07/24/25 and the significant change MDS dated 09/05/25 coded daily use of side rails as a physical restraint. Resident #52 had diagnoses including pain in leg, muscle spasm, pain in right shoulder, muscle weakness, and lack of coordination; the side rail assessment documented grab/assist bars times two to keep the resident as independent as possible with bed mobility, while the quarterly MDS dated 09/02/25 coded daily use of bed rails as a physical restraint. Resident #36 had diagnoses including Alzheimer's disease, pain, muscle weakness, and unsteadiness on feet. The physician order sheet showed Seroquel 25 mg twice daily discontinued on 10/28/25 and changed to 25 mg at bedtime, and the pharmacist note documented the physician agreed with the dose reduction. The annual MDS dated 11/06/25 marked that the resident received antipsychotic medication in the seven-day lookback period and that no gradual dose reduction had been attempted, while also marking that the physician documented GDR as clinically contraindicated and listing 10/28/25 as the date of that documentation. The report stated the facility failed to capture the GDR from 10/28/25 on the MDS.
Failure to Perform Hand Hygiene and Avoid Bare-Hand Contact With Food Items
Penalty
Summary
Facility staff failed to serve food in a manner that reduced the risk of cross contamination and food borne illness when they touched residents’ items and food with bare hands and did not perform hand hygiene between tasks. The facility’s policies required hand hygiene before handling food or meal trays, before and after assisting a resident with eating, after contact with bodily fluids or contaminated surfaces, and after removing gloves. The policies also required gloves when directly handling food and stated that staff should not touch food or the drinking end of straws with bare hands. During the noon meal observation in the Creative Care Unit, Nurse Aides F and G repeatedly handled residents’ food-related items without hand hygiene. Examples included touching the drinking ends of straws while placing them in residents’ cups, removing plates and cups from tables without hand hygiene, taking a straw from a resident’s hand and touching the drinking end before returning it to the cup, handling wrapped silverware and passing a fork to another resident, touching a bun while cutting a resident’s sandwich, moving residents’ plates and cups, picking up tater tots from the table with a napkin and with bare hands, and handing a resident’s cup back to the resident without hand hygiene. One aide also held a resident’s hands to look at painted fingernails and later handled another resident’s used straw and a new straw, touching the drinking end before placing it in the cup. On another noon meal observation, staff continued to handle food and resident items without hand hygiene. One aide opened a creamer packet and used bare fingers on the inside to push it open for a resident. A CNA assisted one resident with lunch and then assisted another resident with eating without performing hand hygiene. The aides and RN interviewed afterward stated they had learned infection control and should wash or sanitize hands before and after resident care, between residents, and should not touch bare food or the drinking end of straws. The IP, RN, Administrator, and DON all stated that hand hygiene was expected before serving residents, between tasks, and when touching food or straws.
Infection Control Lapses During Medication Administration
Penalty
Summary
The facility failed to maintain infection control practices during medication administration for four residents out of nine sampled residents. The cited policy required hand hygiene before handling medications, and the facility's glove and handwashing policies addressed glove use and hand hygiene during resident care, including after glove removal and when moving between contaminated and clean tasks. During observation, a CMT sanitized hands and then administered eye drops to a resident without donning gloves. In another medication pass, the same CMT sanitized hands, removed medications from packaging, placed pills into a cup, inserted an ungloved finger into the cup to separate the medications, picked up capsules with ungloved hands, emptied the capsule contents into another cup, crushed other medications, mixed them with pudding, and administered them to a resident. The CMT also administered eye drops to another resident without gloves and used the same tissue to blot both eyes after administration. A separate LPN sanitized hands, answered the telephone, then did not sanitize hands before donning gloves and obtaining a finger stick blood sugar on one resident, and after removing gloves did not sanitize or wash hands. The LPN also did not wash or sanitize hands before obtaining a Dexcom reading and administering insulin to another resident, and again did not sanitize or wash hands after removing gloves. During interview, the CMT stated he or she should probably wear gloves for eye drop administration and guessed gloves should be worn when touching medications and emptying capsules. The LPN stated he or she should sanitize hands before and after checking blood sugars and between residents, and the Administrator, DON, and MDS Coordinator stated they would expect staff to wear gloves during eye drop administration, use a separate tissue for each eye, and sanitize hands between glove changes and between residents receiving blood sugar checks and insulin administration.
Failure to Perform Regular Bed Rail and Entrapment Inspections
Penalty
Summary
Facility staff failed to conduct regular inspections of bed frames, mattresses, side rails, and enabler bars as part of a maintenance program for Residents #2, #4, and #5. The facility policy reviewed on 06/21/21 stated that the maintenance department would conduct regular inspection of all bed frames, mattresses, and bed rails to identify areas of possible entrapment, and that bed rails should be assessed for entrapment risk prior to installation. However, the maintenance inspection for Resident #2's side rail was completed on 01/09/26, more than six months after the side rail was applied, and the resident was observed in bed with the left side half rail upright on 01/06/26 and 01/09/26. Resident #4's maintenance inspection for the side rail was completed on 01/09/26, more than a year after the side rail was applied, and the resident was observed sitting in a wheelchair next to the bed with the right enabler bar upright on 01/06/26 and 01/07/26. Resident #5 had no maintenance inspection for the side rails, and was observed sitting in a wheelchair next to the bed with the left side half rail upright on 01/08/26. During interviews, the Administrator stated entrapment assessments should have been completed at installation and regular inspections were being completed by the MDS Coordinator, but the logs were not kept. The Maintenance Technician and Maintenance Director stated maintenance did not perform regular inspections or entrapment assessments, and the Administrator later stated the MDS Coordinator tried to complete assessments quarterly but had been throwing them away after completion.
Improper Use of Position Change Alarms Without Physician Orders
Penalty
Summary
The facility failed to properly assess and document the use of position change alarms for five residents, potentially classifying them as restraints. These alarms were used without obtaining a physician's order or conducting an assessment to determine if they were necessary or if they constituted a restraint. The facility's policy on restraints did not identify position change alarms as potential restraints, leading to their use without proper documentation or consent. Resident #59, diagnosed with Alzheimer's disease and other conditions, had a chair alarm in place without a physician's order or assessment. Similarly, Resident #68, with severe cognitive impairment and multiple health issues, had a bed alarm that restricted movement, also lacking proper documentation. Resident #84, with Alzheimer's and dementia, had a bed alarm used as an intervention without a physician's order or assessment. Resident #86, diagnosed with Parkinson's disease and dementia, and Resident #242, with senile degeneration of the brain and other conditions, both had alarms in place without the necessary documentation or physician's orders. Interviews with the DON and Administrator revealed a lack of expectation for orders or assessments for these alarms, relying instead on nurses' discretion, which contributed to the deficiency.
Failure to Provide Written Transfer Notifications
Penalty
Summary
The facility failed to provide written notification to residents and/or their representatives regarding facility-initiated transfers to the hospital for six residents. These residents were transferred for medical evaluations on various dates, but there was no documentation of written notifications being sent. The facility's policy requires that a written notice be sent to the resident and any representative before a transfer or discharge, but this was not adhered to in these cases. Interviews with the Director of Nursing and the Administrator revealed that the facility mailed a Transfer Notice form to the resident's representative, which included transfer notice and bed hold information. However, the facility did not keep copies of these forms, resulting in a lack of documentation to confirm that the notices were sent. This oversight affected six residents out of a sample of seven, with the facility's census being 91.
Failure to Provide Written Bed Hold Policy Information
Penalty
Summary
The facility failed to inform residents and their representatives in writing about the bed hold policy during transfers to the hospital or therapeutic leave, as required by their policy. This deficiency was identified for seven residents out of a sample of seven, with a facility census of 91. The facility's policy mandates that residents and their representatives receive written information about the state's bed hold duration and payment amount before transfer, and documentation of this notice should be included in the resident's medical record. However, reviews of the medical records for the seven residents showed no documentation that the residents or their representatives were informed in writing of the bed hold policy at the time of their transfers. Interviews with the Director of Nursing and the Administrator revealed that the facility mailed a Transfer Notice form, which included bed hold information, to the resident's representative but did not retain copies of these forms. Additionally, the facility did not require signatures to confirm receipt of the bed hold policy information. The Administrator stated that the bed hold policy was explained to residents or their representatives at admission and included in the admission handbook, but there was no documentation to verify that the policy was communicated at the time of transfer.
Improper Transfer Techniques Used for Resident
Penalty
Summary
The facility failed to ensure safe transfer techniques for a resident, leading to a deficiency in accident prevention and supervision. The resident, who was cognitively impaired and required the assistance of two staff members for transfers, was observed being transferred without the use of a gait belt, contrary to the facility's policy. The resident had multiple diagnoses, including Guillain-Barre Syndrome, muscle weakness, and was receiving hospice services, indicating a high level of care and assistance was necessary. During the transfer, two CNAs lifted the resident by placing their arms under the resident's upper arms and holding the back of the resident's pants, instead of using a gait belt as required. Both CNAs expressed that they felt it was safe to transfer residents without a gait belt if two staff members were present. Interviews with the DON and an LPN revealed that they expected staff to use proper transfer techniques, highlighting a discrepancy between staff actions and facility expectations.
Failure to Assess and Document Bed Rail Use Risks
Penalty
Summary
The facility failed to properly assess and document the risks and benefits of bed rail use for six residents, leading to a deficiency in compliance with safety protocols. The facility did not conduct entrapment assessments or obtain informed consent from the residents or their representatives before installing bed rails. This oversight was observed in the cases of six residents, each with varying degrees of cognitive and physical impairments, who were using bed rails without documented assessments or consents. Resident #1, diagnosed with quadriplegia and severe cognitive impairment, was observed with four padded half bed rails for seizure precautions, yet there was no documentation of informed consent or an entrapment assessment. Similarly, Resident #14, with quadriplegia and muscle weakness, used bed rails without documented consent or assessment, despite being dependent on bed mobility. Resident #19, with a history of falls and moderately impaired cognition, also used bed rails without the necessary documentation. Further observations revealed that Resident #40, with severe cognitive impairment and a high fall risk, had an assist bar attached to the bed without proper documentation. Resident #55, suffering from Alzheimer's and severe cognitive impairment, was observed with a half side rail and assist bar, again without documented consent or assessment. Lastly, Resident #68, with severe cognitive impairment and a high fall risk, used bed rails without the required documentation. Interviews with facility staff confirmed the lack of a formal process for assessing and documenting the risks and benefits of bed rail use.
Infection Control Deficiencies in Wound and Catheter Care
Penalty
Summary
The facility failed to maintain proper infection control practices during wound care and catheter care for two residents, as well as during meal tray delivery. For Resident #14, both the LPN and CNA did not wear gowns as required by Enhanced Barrier Precautions (EBP) while performing catheter and wound care. They leaned against the resident and the bed, further breaching infection control protocols. Interviews with the CNA and LPN revealed a misunderstanding of the need for EBP, as they believed extra precautions were only necessary if the resident had an infection. Additionally, during wound care for another resident, the LPN also failed to wear a gown, indicating a consistent issue with adherence to EBP. During meal service, staff members were observed touching trash can lids with bare hands and failing to perform hand hygiene before continuing to deliver meal trays and assist residents with eating. Interviews with staff members and the Director of Nursing confirmed that hand hygiene was expected after touching soiled surfaces, yet this practice was not consistently followed.
Failure to Conduct Regular Bed and Side Rail Inspections
Penalty
Summary
The facility staff failed to conduct regular inspections of bed frames, mattresses, and side rails for six residents out of a sample of 19, with a total facility census of 91. There was no documentation of maintenance assessments for side rails in the medical records of these residents. Observations revealed that residents were in beds with various configurations of side rails and assist bars, but there was no evidence of regular maintenance checks or assessments for entrapment risks. The facility did not provide any side rail maintenance policies. Interviews with the Maintenance Director, Director of Nursing (DON), and the Administrator revealed inconsistencies in the maintenance practices. The Maintenance Director stated that bed rails were installed after nursing assessments and replaced if reported loose, but no entrapment assessments were performed. The DON mentioned that side rails were checked regularly, but there was no documentation of these checks. The Administrator expected regular inspections for entrapment risks, but this expectation was not met, as evidenced by the lack of documentation and maintenance assessments.
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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 Perryville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Estates Of Perryville, Llc, The | 0.7 mi | ★★★★★ | 13 | 0 |
| Three Springs Sr Living & Rhab | 13.4 mi | ★★★★★ | 3 | 0 |
| Riverview At The Park Care And Rehabilitation Cent | 18.3 mi | ★★★★★ | 1 | 0 |
| St Genevieve Nursing | 19.1 mi | ★★★★★ | 6 | 0 |
| Claru Deville Nursing Center | 25.7 mi | ★★★★★ | 19 | 0 |
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