Average — CMS composite of the measures below.
The next survey window likely opens around March 2027
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 Sikeston Convalescent Center during CMS and state inspections, most recent first.
Unsanitary food storage and kitchen sanitation: Surveyors observed uncovered milk and unlabeled, undated food items in the freezer, along with frozen items that were not sealed, labeled, or dated. They also found a loose freezer door seal, worn and dirty dishwashing supplies, buildup on the dish machine, and dirt, debris, and grease on kitchen floors. The Maintenance Log did not show the loose freezer seal had been addressed, and the DM, MS, and Administrator stated food items should be labeled and dated, equipment cleaned after use, and kitchen floors kept free of grease, dirt, and debris.
Failure to Provide Timely Medicare Non-Coverage Notices: The facility did not issue the required SNF ABN and/or NOMNC at least two calendar days before the end of skilled services for two residents. For one resident, both forms were signed on the same day the notice period began, and for another resident, the NOMNC was signed only one day before skilled services ended. The SSD said he/she was not working at the facility at the time and was unsure why one notice was not completed on time, and the Administrator stated the forms should be signed two days prior to discharge from skilled services.
A resident's death in facility MDS assessment was completed but not electronically submitted for validation in a timely manner, and the assessment was accepted 122 days late. The MDS Coordinator said the assessment had not been submitted for validation, and the Administrator stated it should have been completed and submitted within a timely manner.
Failure to include blood thinner interventions in care plans: Two residents had orders for anticoagulants, but their care plans did not address the medications or include resident-specific, person-centered interventions. One resident had CKD, ecchymoses, cerebrovascular disease, TIA history, and prior cerebral infarction and was receiving apixaban for AFib; the other had COPD and paroxysmal AFib and was receiving rivaroxaban. The ADON, Administrator, and DON stated that residents on blood thinners should be addressed in the care plan with specific interventions.
Failure to Follow EBP and PICC Line Infection Control: An LPN and an RN did not consistently use gowns, hand hygiene, or proper disinfection when accessing a resident’s PICC line for IV daptomycin, and an LPN did not follow EBP during a suprapubic catheter dressing change for another resident. Staff accessed the PICC line without proper port disinfection before and after use, and the dressing change was completed with bare hands after gloves were removed.
A resident with severe cognitive impairment and multiple chronic conditions experienced a significant decline, leading to EMS transport to the hospital. Staff did not notify the resident's designated representative or emergency contact as required by facility policy, instead assuming a family member present would relay the information. There was no documentation of direct notification to the emergency contact.
Two residents with cognitive and physical impairments were left in urine-saturated briefs and did not receive complete incontinent care, as staff failed to clean the pelvic and groin areas during hygiene routines. Multiple residents reported delays in being checked or changed, and staff interviews confirmed that all soiled areas should be cleaned, but this was not consistently done.
Staff failed to change gloves and perform hand hygiene between dirty and clean tasks while providing incontinent care to two residents with cognitive and physical impairments. Both residents required extensive assistance, and the facility did not have a policy addressing infection control practices for incontinent care. Interviews confirmed staff should have changed gloves and performed hand hygiene, but this was not done during observed care.
The facility failed to reconcile narcotics at each shift change for all medication carts, affecting all residents. Numerous missed opportunities for reconciliation were found across various shifts and halls. Interviews revealed the absence of a specific policy on narcotic reconciliation, despite staff acknowledging the best practice of having both on-coming and off-going staff sign the log.
The facility failed to maintain sanitary conditions in the kitchen, with grease buildup on cooking pans and dirty cleaning tools on the dish machine. Food items in the walk-in freezer and dry foods area were improperly stored, with several items opened, unsealed, and without labels or dates. Ice buildup was also observed in the freezer. These practices were contrary to the facility's policies, as confirmed by interviews with the dietary staff and administrator.
A facility failed to document a code status for a resident, despite policy requirements for CPR unless a DNAR or DNR order is present. The resident's medical record, including the face sheet, baseline care plan, and Physician's Order Sheet, lacked this documentation. Interviews with the DON and Administrator confirmed the expectation for code status documentation upon admission.
The facility failed to maintain a safe and homelike environment, with observations of spider webs, dirt, exposed sheetrock, and broken mini-blinds. A resident's Geri-chair was also in poor condition, with worn protective covering. Staff interviews revealed a lack of effective documentation and follow-up on maintenance issues.
A facility failed to develop a baseline care plan within 48 hours of admission for a resident, as required by its policy. The plan, which should address immediate health and safety needs and include initial goals and physician orders, was not completed in the specified timeframe. Interviews with the DON and Administrator confirmed the expectation for timely completion, highlighting a deficiency in meeting professional care standards.
A facility failed to ensure an appropriate diagnosis for a resident prescribed Seroquel for depression, contrary to policy requiring specific conditions for antipsychotic use. The resident, with a history of depression, was on Seroquel and Zoloft, but no behaviors or appropriate diagnosis were documented. The resident experienced excessive sleepiness from Seroquel, leading to refusal of the medication, yet it continued to be administered without proper justification.
The facility exceeded the acceptable medication error rate due to improper insulin administration for two residents. An LPN failed to prime insulin pens and did not leave the needle under the skin for the required duration, leading to a 7.41% error rate. Interviews confirmed the need to prime pens with two units, which was not adhered to.
The facility failed to maintain dumpsters properly, leaving lids open and allowing trash to scatter, including soiled briefs and food waste. Staff interviews confirmed that dumpsters should be closed after use, but observations showed mattresses and foam cups scattered around the area.
The facility failed to implement Enhanced Barrier Precautions (EBP) during wound care for several residents. An LPN did not wear an isolation gown while performing wound care, despite the facility's policy requiring gowns and gloves to prevent the transmission of multidrug-resistant organisms. Observations showed that EBP signage was often missing, and interviews with staff confirmed the expectation for gown use, which the LPN admitted to forgetting.
A resident with multiple health conditions suffered a left femur fracture due to an improper transfer by a nurse aide who attempted a two-person assist alone without a gait belt. The incident was not immediately reported, delaying medical assessment and intervention.
A resident's family was not notified after the resident's leg was injured during a transfer, resulting in pain and a subsequent hospital transfer for a fractured femur. Despite the resident's complaints and a request for pain medication, the facility failed to inform the family of the incident and the hospital transfer, as confirmed by staff interviews.
Unsanitary food storage and kitchen sanitation
Penalty
Summary
The facility failed to store and distribute food under sanitary conditions. During observations of the walk-in freezer next to the five-shelf metal rack, surveyors found two uncovered glasses of milk that were not labeled or dated, a bag of shredded cheese that was not labeled or dated, and a rubber seal around the door frame that was unattached and hanging loose. In the walk-in freezer located inside the canned/dry goods area, surveyors observed a buildup of ice and frost on a plastic resealable bag of meat patties that was not labeled or dated, another bag of meat patties that was not sealed, and a large brown paper bag of potato fries that was not sealed, labeled, or dated. Surveyors also observed the dishwashing machine with three worn scour pads, a dirty squeegee, an open bottle of testing strips lying sideways on top, and a buildup of a hard white substance on the top and side surfaces. Kitchen floors had dirt and debris under the steam table, under a table with a coffee maker and coffee supplies, under and behind the stove, under and around the deep fryer, and a grease-like substance around the stove and deep fryer area. The Maintenance Log from 01/01/26 through 04/03/26 had no documentation that the unattached rubber seal on the walk-in freezer door had been addressed. During interviews, the Maintenance Supervisor, Dietary Manager, and Administrator stated that kitchen floors should be clean and free of grease, dirt, and debris, kitchen equipment should be cleaned after each use, food items should be labeled and dated when opened and placed back into the freezer, and maintenance issues should be written on the maintenance log.
Failure to Provide Timely Medicare Non-Coverage Notices
Penalty
Summary
The facility failed to issue a Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN) and/or a Notice of Medicare Non-Coverage (NOMNC) in writing at least two calendar days before discharge from skilled services for two residents. The report states that this notice is used to inform a Medicare beneficiary about potential non-coverage and the option to continue services with financial liability accepted by the beneficiary. The facility's policy required written notice in advance when Medicare payment denial or a change in coverage was likely, and required the NOMNC to be issued at least two calendar days before Medicare-covered services ended. For Resident #100, skilled services ended on 10/23/25 after discharge from skilled services on 10/22/25, and both the NOMNC and SNF ABN were issued and signed on 10/22/25, which did not provide the required two-day notice. For Resident #101, skilled services ended with discharge from skilled services on 02/06/26, and the NOMNC was issued and signed on 02/05/26, which also did not provide at least two calendar days' notice. During interview, the Social Services Designee stated he/she was not working at the facility at the time of the discharges and was unsure why Resident #101's NOMNC was not completed in the appropriate timeframe. The Administrator stated the SNF ABN and NOMNC forms should be signed two days prior to discharge from skilled services.
Late Submission of Death in Facility MDS Assessment
Penalty
Summary
The facility failed to electronically transmit the Minimum Data Set (MDS) assessment to the State within 7 days of assessment for one resident, Resident #53. Review of the record showed the resident was admitted, later expired in the facility, and had a death in facility MDS assessment completed, but there was no validation status showing the assessment had been accepted. The assessment was submitted 122 days late. The facility policy titled Resident Assessments stated that MDS data is submitted to iQIES as required and that the resident assessment coordinator is responsible for ensuring timely and appropriate resident assessments. During interview, the MDS Coordinator stated the death in facility assessment had been completed but had not been accepted because it had not been submitted for validation. The Administrator stated the resident's MDS death in facility assessment should have been completed and submitted within a timely manner for validation purposes.
Failure to Include Blood Thinner Interventions in Care Plans
Penalty
Summary
The facility failed to develop and implement care plans with specific, measurable interventions to meet the individual needs of two residents out of 16 sampled. Review of the facility policy showed that comprehensive person-centered care plans are to include measurable objectives, timeframes, and services needed to attain or maintain the resident’s highest practicable well-being, with interventions based on data gathering and clinical decision making and updated when conditions change. However, the care plans for two residents did not address their blood thinner medications with resident-specific interventions. Resident #7 was admitted with diagnoses including chronic kidney disease, spontaneous ecchymoses, cerebrovascular disease, history of TIA, and cerebral infarction without residual deficits, and had an order for apixaban 5 mg twice daily for atrial fibrillation. Resident #37 was admitted with diagnoses including COPD and paroxysmal atrial fibrillation, and had an order for rivaroxaban 20 mg daily. Their care plans, revised in January 2026, did not address the blood thinner medications or include person-centered interventions. During interviews, the ADON, Administrator, and DON stated that residents on blood thinners should be addressed in the care plan with specific interventions.
Failure to Follow EBP and PICC Line Infection Control
Penalty
Summary
The facility failed to follow Enhanced Barrier Precautions and infection control practices during care for a resident with a PICC line and chronic wound. Resident #30 had diagnoses including osteomyelitis, congestive heart failure, peripheral vascular disease, and an acquired absence of toes on the right foot, and had an order to flush the PICC line with normal saline before and after each medication administration. During observation of IV daptomycin administration, an LPN performed hand hygiene and wore gloves but did not put on a gown, removed the disinfection cap, and accessed the PICC line without disinfecting the port before attaching the saline syringe. The LPN flushed the line, connected the IV tubing, and later removed gloves and exited the room without hand hygiene. In a later observation, the same LPN again did not perform hand hygiene or wear a gown, and the PICC line port touched the resident’s pants after being disinfected. The port was not scrubbed for at least 15 seconds, and after flushing, the port was not disinfected before reconnecting the IV tubing. During disconnection, the port was again not disinfected before flushing and before the disinfection cap was applied. An RN later administered the IV medication while wearing gloves but not a gown. The facility also failed to follow EBP during care for a resident with a suprapubic catheter. Resident #75 had diagnoses of COPD and neuromuscular dysfunction of the bladder and had orders for a urinary catheter and suprapubic catheter care every shift. During observation of a suprapubic catheter dressing change, an LPN did not perform hand hygiene, put on gloves, and did not wear a gown. The LPN cleaned the insertion site, removed gloves, performed hand hygiene, then applied the split dressing with bare hands, secured it with tape, dated and initialed the dressing, and exited the room without hand hygiene. The Infection Preventionist, ADON, and DON stated that residents with wounds or indwelling devices such as urinary catheters or PICC lines were on EBP and that staff should wear gowns and gloves for direct care and disinfect PICC line connectors before and after access. The facility policy stated that EBP was to be initiated for residents with wounds or indwelling medical devices, including central lines and urinary catheters, and that gowns and gloves should be available near the room. The policy for peripheral and midline IV catheter flushing and locking also required disinfecting the needleless access device before and after access. Despite these requirements, staff did not consistently use gowns, did not consistently perform hand hygiene, did not consistently disinfect the PICC line port before and after access, and handled the suprapubic catheter dressing with bare hands.
Failure to Notify Resident Representative After Significant Change in Condition
Penalty
Summary
The facility failed to follow its policy regarding notification of a resident's designated representative or emergency contact after a significant change in the resident's condition. Specifically, for one resident with severe cognitive impairment and multiple chronic diagnoses, including diabetes mellitus, Alzheimer's disease, anemia, chronic kidney disease, and COPD, there was no documentation that the resident's representative or emergency contact was notified when the resident experienced a decline in condition. The resident became lethargic, cold, and unresponsive, prompting staff to call EMS, who subsequently transported the resident to the hospital. Despite the presence of a family member at the facility during the incident, the emergency contact listed in the resident's records was not notified, and there was no documentation of any attempt to contact the designated representative. Interviews with staff and administration revealed a misunderstanding, as the administrator assumed the family member present would inform the emergency contact, contrary to facility policy, which requires direct notification by staff. This lapse resulted in a failure to ensure proper communication with the resident's representative during a critical change in the resident's status.
Failure to Provide Complete Incontinent Care and Timely Checks
Penalty
Summary
The facility failed to provide appropriate care and services to two residents who were incontinent of bladder, resulting in both being left in urine-saturated briefs with a strong urine odor. Observations revealed that during incontinent care, staff did not adequately clean the residents' pelvic and groin areas, only washing the buttocks and backs of the legs before applying a clean brief. This incomplete hygiene practice was observed for both residents, despite their care plans indicating a need for extensive assistance with activities of daily living, including toileting and hygiene. Resident #4 had a history of cerebral infarction, hemiplegia, hemiparesis, and vascular dementia, with moderate cognitive impairment and dependence for toileting hygiene. Resident #5 had diagnoses including Parkinsonism, ataxia, spinal stenosis, and hemiplegia, also with moderate cognitive impairment and dependence for toileting hygiene. Both residents were observed to be left in urine-saturated briefs prior to care, and the care provided did not include cleaning of the front and peri areas as required. Interviews with residents indicated delays in being checked or changed, with some residents reporting being left wet for extended periods and staff not returning after call lights were activated. Staff interviews confirmed that all soiled areas should be cleaned during incontinent care, and the DON stated that residents should be checked every two hours if incontinent. However, the facility lacked a specific policy on the timing of incontinence checks, and the observed care did not meet the expected standards for thorough cleaning.
Failure to Follow Infection Control Practices During Incontinent Care
Penalty
Summary
The facility failed to implement proper infection prevention and control practices during incontinent care for two residents with significant cognitive and physical impairments. Observations revealed that staff, including nurse aides and certified nurse aides, did not change gloves or perform hand hygiene between dirty and clean tasks while providing care to residents who were incontinent of bladder and bowel. Specifically, after unfastening and removing urine-saturated briefs and washing the residents' buttocks and legs, staff proceeded to place clean briefs and secure them without changing gloves or performing hand hygiene in between these steps. Both residents involved had moderate cognitive impairment and required extensive assistance with activities of daily living, including toileting hygiene. The facility also lacked a policy addressing infection control practices during incontinent care. Interviews with the Infection Preventionist and the Director of Nursing confirmed that staff should have changed gloves and performed hand hygiene between dirty and clean tasks, while one staff member was unaware of any mistakes made during the care provided.
Failure to Reconcile Narcotics at Shift Changes
Penalty
Summary
The facility failed to ensure proper reconciliation of narcotics at each shift change for all five medication carts, potentially affecting all residents. The review of narcotic count logs revealed numerous missed opportunities for reconciliation across various shifts and halls. For instance, on A Hall, staff missed 11 out of 44 opportunities during the 7 A.M. - 7 P.M. shift from 11/27/24 to 12/18/24, and 13 out of 44 opportunities during the 7 P.M. - 7 A.M. shift from 12/18/24 to 01/08/25. Similar patterns of missed reconciliations were observed in B Hall, C Hall, D Hall, and the Medication Room Nurse Narcotic Count Log, indicating a widespread issue with narcotic reconciliation practices. Interviews with staff, including a Certified Medical Technician (CMT), the Corporate Nurse, the Director of Nursing, and a Licensed Practical Nurse (LPN), confirmed that the facility lacked a specific policy on narcotic reconciliation documentation. Although it was acknowledged as best practice for both on-coming and off-going staff to sign the narcotic reconciliation log, this was not consistently followed. The Administrator also confirmed the absence of a specific policy, despite recognizing the importance of having two staff sign off for each shift. This lack of policy and inconsistent practice led to the deficiency in narcotic reconciliation.
Sanitation and Food Storage Deficiencies in Kitchen
Penalty
Summary
The facility failed to maintain sanitary conditions in the food service area, as observed during a survey. There was a buildup of grease and a black substance on several cooking pans stored on metal shelf racks, and a white substance on the dish machine. Additionally, dirty cleaning tools and debris were found on top of the dish machine, and soiled blankets were on the floor in front of it. These conditions indicate a lack of proper cleaning and sanitization of kitchen equipment, which is contrary to the facility's policy requiring daily cleaning and sanitization. Furthermore, the facility did not properly store food items in the walk-in freezer and dry foods area. Several food items, including mozzarella cheese, sliced cheeses, and various frozen goods, were found opened, unsealed, and without labels or dates. The walk-in freezer also had significant ice buildup on the floor and under metal racks. The facility's policy mandates that all foods be sealed, labeled, and dated once opened, and that the freezer be free of ice buildup. Interviews with the Assistant Dietary Manager, Dietary Manager, and Administrator confirmed that these practices were expected but not followed, leading to the observed deficiencies.
Failure to Document Code Status for a Resident
Penalty
Summary
The facility failed to document a code status for a resident outside the sample of 17 residents, with a total facility census of 66. The facility's policy on Cardiopulmonary Resuscitation (CPR) requires that CPR be provided unless there is a physician's order for no CPR, such as a Do Not Attempt Resuscitation (DNAR) or Do Not Resuscitate (DNR) order. However, the policy did not address the documentation of code status throughout the resident's medical record. Upon review, it was found that the medical record of a resident admitted with diagnoses including a urinary tract infection, altered mental status, and cerebral infarction, lacked documentation of a code status on the face sheet, baseline care plan, Physician's Order Sheet (POS), and care plan. Interviews with the Director of Nursing (DON) and the Administrator revealed that both expected the code status to be documented on the baseline care plan upon a new resident's admission. If not documented there, it should be present on the face sheet, POS, and care planned. The absence of this documentation indicates a failure to adhere to the facility's expectations and policy regarding the documentation of code status, which is crucial for ensuring appropriate emergency care decisions are made for residents.
Facility Fails to Maintain Safe and Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment for its residents, as evidenced by multiple observations of environmental deficiencies. Over several days, surveyors noted a buildup of spider webs and dirt on the outside ceilings of the awnings at the front entrance and near the personnel dining room and kitchen. Inside the facility, rooms were observed with exposed sheetrock, peeled paint, and dark scuff marks on the walls. Additionally, broken slats were noted on a mini-blind in one of the rooms. These conditions were not documented in the maintenance log, indicating a lack of monitoring and timely addressing of environmental concerns. Resident #4's equipment was also found to be in poor condition, with the protective covering worn off and rough edges on the left-side armrest of their Geri-chair. This was observed while the resident was using the chair in the dining room, potentially affecting their comfort and safety. Interviews with the Maintenance Supervisor, Administrator, and Housekeeper A revealed that there was an expectation for staff to document environmental issues in a maintenance log, but this was not being done effectively. The maintenance and housekeeping staff were responsible for addressing these issues, but the lack of documentation and follow-up led to the deficiencies observed.
Failure to Implement Baseline Care Plan Within 48 Hours
Penalty
Summary
The facility failed to develop and implement a baseline care plan within 48 hours of admission for a resident, identified as Resident #9, which is a requirement according to the facility's policy. The baseline care plan is intended to address the resident's immediate health and safety needs and should include instructions for effective, person-centered care that meets professional standards. The policy specifies that this plan must include initial goals based on admission orders, discussions with the resident or their representative, and physician orders. However, the baseline care plan for Resident #9 was not completed within the required timeframe, as evidenced by the medical record showing the plan dated after the 48-hour window. Interviews with the Director of Nursing (DON) and the Administrator confirmed the expectation that a baseline care plan should be completed within 48 hours of a new admission. Both acknowledged that the plan should reflect pertinent information regarding the resident's care areas. Despite these expectations, the facility did not adhere to its policy, resulting in a deficiency in meeting the professional standards of quality care for Resident #9.
Inappropriate Use of Psychotropic Medication Without Proper Diagnosis
Penalty
Summary
The facility failed to ensure an appropriate diagnosis for the use of a psychotropic medication for Resident #45. The resident was prescribed Seroquel, an antipsychotic medication, for depression without proper documentation of behaviors or an appropriate diagnosis. The facility's policy requires that antipsychotic medications be used only for specific conditions as documented in the Diagnostic and Statistical Manual of Mental Disorders, and Seroquel was not indicated for the treatment of insomnia or depression in this case. Resident #45 had a medical history of congestive heart failure, type 2 diabetes mellitus, muscle weakness, and insomnia. The resident was on several different depression medications in the past without success and was started on Seroquel along with Zoloft to improve symptoms. However, there was no documentation of behaviors or an appropriate diagnosis for the use of Seroquel. The resident's diagnosis was later corrected to major depressive disorder, but the pharmacy consultant noted that Seroquel was not indicated for the treatment of insomnia or depression. Interviews with facility staff revealed that the resident had not exhibited any behaviors that would warrant the use of Seroquel. The resident reported that the medication caused excessive sleepiness, leading to refusal of the medication. The Director of Nursing acknowledged that the recommendations from the pharmacy consultant were sent to the physicians, but the issue persisted. The facility staff had requested a decrease in the Seroquel dosage due to the resident's complaints, but the medication was still being administered without a proper diagnosis.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate of less than five percent, resulting in a rate of 7.41% due to errors in insulin administration for two residents. The errors were observed during medication administration for two residents, where the Licensed Practical Nurse (LPN) did not follow the manufacturer's instructions for priming the insulin pens and did not leave the needle under the skin for the recommended duration. Specifically, the LPN administered insulin without priming the pen with the required two units and removed the needle from the skin too quickly, contrary to the instructions for both the Humalog and Fiasp insulin pens. Resident #7 had orders for insulin aspart to be administered subcutaneously before meals, with a specific sliding scale based on blood sugar levels. During an observation, the LPN administered 9 units of insulin aspart but failed to prime the pen and did not leave the needle under the skin for the required time. Similarly, Resident #16 had orders for Humalog insulin with a sliding scale, and the LPN administered 3 units without priming the pen and removed the needle too soon. Interviews with the LPN, another nurse, and the Director of Nursing confirmed the requirement to prime the insulin pens with two units before administration, which was not followed in these instances.
Improper Disposal and Maintenance of Dumpsters
Penalty
Summary
The facility failed to ensure that the dumpsters were closed and maintained properly to prevent pest access and contain garbage. Observations over several days revealed that the dumpster lids were left open, with visible trash including boxes, trash bags, soiled briefs, gloves, and scattered food. Additionally, a bed mattress and a box spring mattress were found on the ground near the dumpsters, along with scattered white foam cups and bowls. Interviews with various staff members, including the Assistant Dietary Manager, Dietary Manager, Maintenance Supervisor, and the Administrator, confirmed that staff were expected to close the dumpster lids after discarding trash. The Maintenance Supervisor was responsible for the upkeep of the outside grounds, and the Administrator expected no debris or large items to be left around the dumpsters. Housekeeper A also stated that staff should always close the dumpster lids after discarding trash.
Failure to Implement Enhanced Barrier Precautions During Wound Care
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) during wound care for several residents, as observed during a survey. The facility's policy on EBP, which is designed to prevent the transmission of multidrug-resistant organisms, requires the use of gowns and gloves during high-contact resident care activities, such as wound care. However, during observations, it was noted that the Licensed Practical Nurse (LPN) did not wear an isolation gown while performing wound care on multiple residents, despite the presence of wounds that required such precautions. For Resident #60, the LPN did not wear an isolation gown while changing a dressing on the resident's left heel. Similarly, for Resident #32, the LPN failed to don a gown while cleaning a wound on the coccyx. In both cases, EBP signage was not posted outside the residents' rooms. For Residents #46, #45, and #24, although EBP signage was present, the LPN still did not wear a gown during wound care procedures. Additionally, Resident #3's wound care was conducted without a gown and without EBP signage outside the room. Interviews with facility staff, including the Corporate Nurse, Infection Preventionist, and Director of Nursing, confirmed that the expectation was for staff to wear gowns and gloves when providing care to residents with wounds or other conditions requiring EBP. The LPN involved acknowledged forgetting to wear a gown during the wound care procedures. This oversight indicates a failure to adhere to the facility's infection control policy, potentially increasing the risk of transmission of multidrug-resistant organisms.
Improper Transfer Technique Leads to Resident Injury
Penalty
Summary
The facility failed to provide a safe transfer for a resident, resulting in a significant injury. A nurse aide attempted to transfer a resident, who required a two-person assist, alone by bear hugging and pivoting the resident. This improper technique led to the resident's left leg twisting and ultimately resulted in a left femur fracture. The resident, who had a history of hypertension, peripheral vascular disease, heart failure, and diabetes mellitus, was dependent on assistance for chair to bed transfers, as documented in their care plan. The incident occurred when the nurse aide, NA A, did not wait for assistance from CNA B and attempted the transfer alone without using a gait belt, which was against the facility's policy. During the transfer, the resident's weight caused them to slide, and their left leg became entangled in the wheelchair, leading to the injury. Despite the resident's complaints of leg pain following the incident, the aides involved did not immediately report the incident to the nursing staff, delaying appropriate medical assessment and intervention. The Director of Nursing (DON) and other nursing staff were not made aware of the incident until much later, which hindered timely monitoring and treatment of the resident's injury. The lack of communication and failure to follow established transfer protocols contributed to the severity of the resident's injury. The incident was not documented in the electronic medical record until several days later, further complicating the situation and delaying necessary medical care.
Failure to Notify Family of Resident's Injury and Hospital Transfer
Penalty
Summary
The facility failed to notify a resident's family in a timely manner after an incident where the resident's left leg became entangled in a wheelchair during a transfer, resulting in pain and subsequent injury. The resident, who had diagnoses including hypertension, peripheral vascular disease, heart failure, and diabetes mellitus, was dependent on assistance for chair-to-bed transfers and had a moderate cognitive impairment. Despite the resident's complaints of pain and a request for pain medication, there was no documentation of the family or responsible party being notified of the incident. Further, the facility did not inform the family when the resident was transferred to the hospital due to increased pain in the affected leg, which was later diagnosed as a fractured femur. Interviews with staff revealed that the family should have been notified of both the incident and the hospital transfer, but this did not occur. The responsible party only became aware of the situation when visiting the resident and finding them absent from the facility, having been sent to the hospital without prior notification.
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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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Nursing homes near Sikeston
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Hunter Acres Caring Center | 1.2 mi | ★★★★★ | 0 | 0 |
| Clearview Nursing Center | 1.2 mi | ★★★★★ | 14 | 0 |
| Delta South Nursing & Rehabilitation | 1.7 mi | ★★★★★ | 8 | 0 |
| Annie's Garden Skilled Nursing | 2 mi | — | 0 | 0 |
| Bertrand Nursing And Rehab Center | 6.9 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.