Inspection Reports for
Hunter Acres Caring Center
628 NORTH WEST ST, SIKESTON, MO, 63801-4738
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
9 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
64% worse than Missouri average
Missouri average: 5.5 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
87 residents
Based on a August 2025 inspection.
Occupancy over time
Inspection Report
Routine
Census: 87
Deficiencies: 9
Date: Aug 7, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident rights, environment, medication management, employee background checks, resident assessments, care planning, physician orders, nutrition, and pest control.
Findings
The facility was found deficient in multiple areas including failure to ensure correct code status for residents, inadequate environmental cleanliness, failure to follow medication regimen review recommendations, incomplete employee background checks prior to hire, inaccurate resident assessments, incomplete care plans, failure to follow physician orders, failure to implement dietitian recommendations, and ineffective pest control program.
Deficiencies (9)
Failed to ensure correct code status for residents including failure to address and receive orders for code status.
Failed to provide a safe, clean, comfortable homelike environment with issues such as smeared substances, spider webs, peeling paint, and strong odors.
Failed to attempt and ensure physician response to gradual dose reductions for psychotropic medications and failed to limit PRN psychotropic medication orders to 14 days.
Failed to complete criminal background checks and check Employee Disqualification List prior to hire for three employees.
Failed to accurately code Minimum Data Set assessments for residents regarding PASRR Level II screening.
Failed to establish care plans addressing residents' use of non-invasive mechanical ventilators such as BiPAP and CPAP.
Failed to follow physician's written orders for medication discontinuation, resulting in continued administration of discontinued medication.
Failed to implement dietitian recommendations for a resident with excessive weight loss, including failure to provide house supplements and extra portions.
Failed to maintain an effective pest control program, resulting in presence of flies in dining areas and non-functioning insect light traps.
Report Facts
Facility census: 87
Weight loss percentage: 8.94
Weight loss percentage: 5.56
Medication doses administered after discontinuation: 29
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN) I | Licensed Practical Nurse | Reviewed resident's OHDNR form and was uncertain about resident's code status |
| Director of Nursing (DON) | Director of Nursing | Interviewed regarding code status orders, medication regimen reviews, care plans, and pest control expectations |
| Housekeeping Staff L | Housekeeping Staff | Provided information about cleaning schedules and checklists |
| Maintenance Director | Maintenance Director | Provided information about housekeeping and cleaning procedures |
| Pharmacist G | Pharmacist | Provided information about medication regimen reviews and gradual dose reductions |
| Administrator | Administrator | Interviewed regarding facility policies, background checks, medication orders, care plans, and pest control |
| Physician Assistant (PA) | Physician Assistant | Discovered continued administration of discontinued medication for Resident #2 |
| Licensed Practical Nurse (LPN) H | Licensed Practical Nurse | Entered physician orders into electronic medical record and provided information about medication administration |
| Certified Nurse Aide (CNA) E | Certified Nurse Aide | Reported presence of flies in dining area |
| Certified Nurse Aide (CNA) F | Certified Nurse Aide | Observed swatting flies in facility |
| Care Plan Coordinator | Care Plan Coordinator | Provided information about care plan updates and resident needs |
| Dietitian | Dietitian | Provided nutritional assessments and recommendations for residents |
Inspection Report
Complaint Investigation
Census: 86
Deficiencies: 3
Date: Aug 8, 2024
Visit Reason
The inspection was conducted due to complaints regarding the facility's failure to provide appropriate treatment and care according to professional standards, specifically failing to notify the physician immediately of a resident's significant change in status and failing to provide timely emergency treatment for another resident, as well as failure to address significant weight loss in a resident.
Complaint Details
The complaint investigation focused on two residents. Resident #22 experienced a significant change in condition that was not immediately reported to the physician, resulting in delayed hospital transfer. Resident #58 was found unresponsive and experienced delayed emergency response and significant weight loss that was not adequately addressed. Both residents were admitted to ICU with serious diagnoses. The facility was found deficient in timely notification and emergency care.
Findings
The facility failed to notify the physician immediately of Resident #22's significant change in condition and failed to provide timely emergency treatment for Resident #58. Additionally, the facility failed to timely and effectively address significant weight loss for Resident #58. The facility census was 86. Deficiencies were noted in communication, emergency response, and nutritional care.
Deficiencies (3)
Failed to notify the physician immediately of Resident #22's significant change in status.
Failed to provide emergency treatment in a timely manner for Resident #58.
Failed to timely and effectively address significant weight loss for Resident #58.
Report Facts
Resident census: 86
Weight loss: 52
Weight loss: 23
Vital signs: 84
Vital signs: 101.4
Vital signs: 102.5
Medication dosage: 325
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN B | Licensed Practical Nurse | Assessed Resident #58, instructed CNAs, delayed ambulance call |
| LPN D | Licensed Practical Nurse | Described notification procedures for Resident #22 |
| NP F | Nurse Practitioner | On call during Resident #22 and #58 incidents, gave orders and confirmed delayed notifications |
| Administrator | Expected immediate physician notification for significant resident condition changes | |
| Psychiatric Physician's Assistant H | Psychiatric Physician's Assistant | Documented Resident #58's delusional behavior and refusal of care |
| Registered Dietician | Registered Dietician | Recommended nutritional interventions for Resident #58 |
| Certified Medication Technician G | Certified Medication Technician | Reported Resident #58 was able to feed self without assistance |
| Director of Nursing | Director of Nursing | Involved in notification and care decisions for Resident #58 |
Inspection Report
Annual Inspection
Census: 86
Deficiencies: 4
Date: Aug 8, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory standards related to resident care, environment, medication administration, and other facility operations at Hunter Acres Caring Center.
Findings
The facility was found deficient in multiple areas including failure to maintain a safe and homelike environment, failure to notify physicians immediately of significant resident condition changes, failure to provide timely emergency treatment, failure to address significant weight loss in a resident, and failure to maintain medication error rates below 5%. Deficiencies were noted to have minimal harm or potential for actual harm affecting a few residents.
Deficiencies (4)
Failed to provide a safe, clean, comfortable homelike environment with issues such as scratched/peeled paint, holes in walls and doors, and brown/black substances on ceiling vents.
Failed to notify the physician immediately of a resident's significant change in status and failed to provide emergency treatment in a timely manner for two residents.
Failed to timely and effectively address significant weight loss for one resident, including inadequate care planning and insufficient dietician involvement.
Failed to maintain medication error rate below 5%, with two medication errors out of 36 opportunities.
Report Facts
Facility census: 86
Medication error opportunities: 36
Medication errors: 2
Medication error rate: 5.56
Resident weight loss: 52
Resident weight loss percentage: 24.2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN D | Licensed Practical Nurse | Named in medication error finding for failing to administer Novolog insulin and in failure to notify physician immediately |
| CMT C | Certified Medication Technician | Named in medication error finding for failing to administer Crestor |
| LPN B | Licensed Practical Nurse | Named in failure to provide timely emergency treatment for Resident #58 |
| NP F | Nurse Practitioner | On-call nurse practitioner confirming delayed notification and emergency treatment |
| Psychiatric Physician's Assistant H | Psychiatric Physician's Assistant | Documented resident's delusional behavior affecting care and weight loss |
| Registered Dietician | Registered Dietician | Named in failure to provide adequate nutritional intervention for Resident #58 |
| Administrator | Facility Administrator | Provided expectations regarding resident care and medication management |
| Director of Nursing | Director of Nursing | Provided expectations regarding resident care and medication management |
Inspection Report
Complaint Investigation
Census: 87
Deficiencies: 1
Date: Nov 7, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding inadequate supervision of a resident assessed as an elopement risk who left the facility unsupervised during a smoke break.
Complaint Details
Complaint MO00226893. The complaint involved a resident who left the facility unsupervised during a smoke break. The resident was found 30 miles away and taken to a hospital. The supervising CNA admitted to leaving the resident alone and was terminated. The facility policies required constant supervision of residents at risk of elopement during smoking.
Findings
The facility failed to provide adequate supervision for Resident #1, who left the facility unsupervised and was found approximately 30 miles away. The supervising staff member was terminated for not adhering to facility policy. The facility implemented protocols and in-serviced staff on protective oversight following the incident.
Deficiencies (1)
Failed to provide adequate supervision for a resident assessed as an elopement risk, resulting in the resident leaving the facility unsupervised.
Report Facts
Residents present during inspection: 87
Distance resident was found from facility (miles): 30
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA A | Certified Nurse Assistant | Supervising staff who left the resident alone during smoke break and was terminated for policy violation |
| RN B | Registered Nurse | Charge nurse on duty who observed the gate open and initiated search for the missing resident |
| DON | Director of Nursing | Interviewed regarding supervision policies and resident status |
Inspection Report
Routine
Census: 84
Deficiencies: 10
Date: May 5, 2023
Visit Reason
The inspection was a routine survey conducted to assess compliance with federal regulations regarding resident care, medication management, infection control, and documentation.
Findings
The facility was found deficient in multiple areas including failure to maintain adequate surety bond coverage, inconsistent documentation of residents' code status, failure to issue required Medicare notices, untimely completion of Minimum Data Set (MDS) assessments, inaccurate MDS documentation, incomplete care plans, medication administration and reconciliation discrepancies, improper medication storage, and lapses in infection prevention and control practices.
Deficiencies (10)
Failed to maintain surety bond amount at one and one half times the average monthly balance of residents' personal funds.
Failed to ensure consistent code status documentation for one resident.
Failed to issue Medicare Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) for two residents.
Failed to complete comprehensive Minimum Data Set (MDS) assessments within required timeframes for three residents.
Failed to complete quarterly MDS assessments within required timeframes for eleven residents.
Failed to document accurate MDS assessments for four residents.
Failed to develop and implement complete care plans addressing individual resident needs for three residents.
Failed to ensure accurate medication administration, documentation, disposal, and reconciliation for two residents.
Failed to ensure proper labeling and storage of medications including failure to date opened vials and maintain refrigerator cleanliness.
Failed to implement infection prevention and control practices including improper glove use, hand hygiene, and wound care procedures.
Report Facts
Facility census: 84
Surety bond amount: 168000
Average monthly balance: 139154.54
Required bond amount: 208500
Residents sampled: 18
Hydrocodone-APAP tablets discrepancy: 1
Hydrocodone-APAP tablets discrepancy: 1
Eight Hour/Shift Verification blanks: 29
Eight Hour/Shift Verification blanks: 120
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN D | Licensed Practical Nurse | Named in wound care infection control deficiencies and improper hand hygiene |
| CMT I | Certified Medication Technician | Named in medication reconciliation discrepancies and improper documentation |
| CMT C | Certified Medication Technician | Named in failure to perform hand hygiene during medication administration |
| CNA A | Certified Nurse Aide | Named in failure to change gloves and perform hand hygiene during pericare |
Viewing
Loading inspection reports...
