Inspection Reports for
Hunter Acres Caring Center
628 NORTH WEST ST, SIKESTON, MO, 63801-4738
Back to Facility ProfileDeficiencies (last 8 years)
Deficiencies (over 8 years)
13.4 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
144% worse than Missouri average
Missouri average: 5.5 deficiencies/yearDeficiencies per year
28
21
14
7
0
Occupancy
Latest occupancy rate
73% occupied
Based on a August 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy rate 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
Annual Inspection
Census: 86
Deficiencies: 10
Date: Aug 8, 2024
Visit Reason
The inspection was an annual survey conducted to assess compliance with federal regulations for Hunter Acres Caring Center, focusing on quality of care, environment, medication administration, nutrition, and hydration.
Findings
The facility failed to provide a safe, clean, and homelike environment, ensure timely notification of significant changes in residents' conditions, maintain medication error rates below 5%, and adequately address nutrition and hydration needs for residents. Multiple deficiencies were cited related to environment maintenance, quality of care, medication errors, and nutrition/hydration.
Deficiencies (10)
F584 Safe/Clean/Comfortable/Homelike Environment: The facility failed to maintain a safe, clean, and comfortable environment, including damaged walls, ceiling tiles with substances, and holes in bathroom doors. The facility census was 86.
F684 Quality of Care: The facility failed to notify the physician immediately of significant changes in residents' status and provide timely emergency treatment for one resident. The facility census was 86.
F692 Nutrition/Hydration Status Maintenance: The facility failed to timely and effectively address significant weight loss for one resident and ensure proper hydration and nutrition. The facility census was 86.
F759 Free of Medication Error Rates 5 Percent or More: The facility failed to maintain a medication error rate below 5%, with an error rate of 5.56% for two residents out of five sampled. The facility census was 86.
A3038 Furniture/Equipment, Provide Comfort & Safety: The facility failed to maintain furniture and equipment in good condition, with broken, torn, or heavily soiled items.
A3039 Rooms Neat, Orderly, Cleaned Daily: The facility failed to keep rooms neat, orderly, and cleaned daily.
A4055 Safe/Effective Medication System: The facility failed to maintain a safe and effective medication distribution and administration system.
A4075 Nursing Care per Resident Condition: The facility failed to provide nursing care consistent with residents' conditions.
A4079 Sufficient Fluids/Hydration: The facility failed to provide residents with sufficient fluids to maintain proper hydration.
A5001 Nutritional Needs Met, Assess Resident, Inform Doctor: The facility failed to meet residents' nutritional needs and keep the physician informed of nutritional status.
Report Facts
Facility census: 86
Medication error opportunities: 36
Medication error rate: 5.56
Inspection Report
Life Safety
Census: 86
Deficiencies: 8
Date: Aug 8, 2024
Visit Reason
The inspection was conducted to assess compliance with the 2012 Existing Edition of the Life Safety Code of the National Fire Protection Association (NFPA) and related fire safety regulations.
Findings
The facility failed to maintain high hazardous areas free of penetrations through smoke barriers, maintain the range hood in accordance with NFPA 96, maintain required sprinkler system inspections, and adequately secure oxygen cylinders. These deficiencies potentially affected all residents and staff.
Deficiencies (8)
K321 Hazardous Areas - The facility failed to maintain high hazardous areas free of penetrations through smoke barriers, including unsealed pipe penetrations and air vents. This affected all residents and staff.
K324 Cooking Facilities - The facility failed to maintain the range hood in accordance with NFPA 96, including grease-loaded filters, an incorrectly installed filter allowing grease to pass into the vent hood, and a missing cap on a fire suppression system nozzle.
K353 Sprinkler System - The facility failed to maintain required sprinkler system inspections in the kitchen area, including a broken pull station glass rod and outdated inspection tags.
K923 Gas Equipment - The facility failed to adequately secure oxygen cylinders and ensure proper separation to prevent confusion during emergencies. This affected all residents and staff.
A2008 Hazardous Areas - The facility did not meet the requirement for hazardous areas to be separated by at least a one-hour fire resistant construction or protected by an automatic sprinkler system.
A2010 Oxygen Storage - Oxygen storage was not in accordance with NFPA 99, including failure to use permanent racks or fasteners and maintain safety caps intact.
A2017 Range Hood Certification - The range hood and extinguishing system were not certified at least twice annually as required by NFPA 96.
A2034 Sprinkler System-Test/Maintain - The sprinkler system was not inspected, maintained, or tested in accordance with requirements for facilities with pre-2007 sprinkler systems.
Report Facts
Facility census: 86
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
Plan of Correction
Census: 87
Deficiencies: 1
Date: Nov 7, 2023
Visit Reason
The visit was conducted to address a past non-compliance related to accident hazards and supervision, specifically regarding an incident where a resident left the facility unsupervised during a smoke break.
Complaint Details
Complaint MO00226893 was investigated related to the resident elopement incident.
Findings
The facility failed to provide adequate supervision for one resident who eloped during a supervised smoke break and was found approximately 30 miles away. The facility conducted an investigation, implemented protocols, and terminated the staff member responsible for the lapse in supervision.
Deficiencies (1)
F 689 Free of Accident Hazards/Supervision/Devices: The facility failed to provide adequate supervision for one resident who left the facility unsupervised during a smoke break and was found 30 miles away. The resident had impaired memory and was at elopement risk.
Report Facts
Facility census: 87
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
Life Safety
Census: 85
Deficiencies: 6
Date: May 5, 2023
Visit Reason
The inspection was a life safety code survey conducted to assess compliance with fire safety and emergency preparedness regulations at Hunter Acres Caring Center.
Findings
The facility failed to properly maintain means of egress, maintain cooking facilities in functioning order, maintain sprinkler systems, and ensure proper mounting of fire extinguishers. These deficiencies potentially affected all residents and staff.
Deficiencies (6)
K222 Egress Doors: The facility failed to properly maintain means of egress to ensure rapid removal of occupants in an emergency. The 300 Hall exit door did not release with the fire alarm and a gate in the courtyard was locked with a combination lock.
K324 Cooking Facilities: The facility failed to maintain cooking facilities in functioning order. The range hood had two missing filters and the filters in place were covered with a yellow, tacky substance.
K353 Sprinkler System - Maintenance and Testing: The facility failed to maintain sprinkler heads in proper working order. Four sprinkler heads in the laundry room were coated in dust and debris.
K355 Portable Fire Extinguishers: The facility failed to ensure all fire extinguishers were mounted according to code. A fire extinguisher near room 209 was mounted at six feet from the floor to the top of the handle.
A2016 Fire Extinguisher UL/FM, Monthly Check: The facility did not meet requirements for monthly pressure checks and maintenance of fire extinguishers as evidenced by deficiencies in K355.
A2034 Sprinkler System-Test/Maintain: The facility did not meet requirements for inspection, maintenance, and testing of sprinkler systems as evidenced by deficiencies in K353.
Report Facts
Facility census: 85
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 |
Inspection Report
Complaint Investigation
Census: 90
Deficiencies: 2
Date: May 24, 2022
Visit Reason
The inspection was conducted in response to allegations of abuse, neglect, exploitation, or mistreatment involving a resident injury of unknown origin.
Complaint Details
Complaint #MO201535 was investigated regarding an injury of unknown origin to Resident #1. The injury was not properly reported or investigated by the facility staff, and no incident report was completed.
Findings
The facility failed to investigate and report an injury of unknown origin to the state licensing agency within the required timeframe. Documentation and investigation protocols were not properly followed, and an injury to a resident was not adequately reported or investigated.
Deficiencies (2)
F609: The facility failed to investigate and report an injury of unknown origin to the state licensing agency within the required timeframe following allegations of abuse or neglect.
A4074: Each resident shall receive personal attention and nursing care consistent with current acceptable nursing practice. This regulation was not met as evidenced by the issues referenced in F609.
Report Facts
Facility census: 90
Inspection Report
Routine
Deficiencies: 0
Date: Sep 21, 2021
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control survey was conducted to assess compliance with relevant CMS and CDC guidelines.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness and with CMS and CDC recommended practices for COVID-19 infection control.
Inspection Report
Life Safety
Census: 86
Deficiencies: 4
Date: Apr 9, 2021
Visit Reason
The inspection was conducted to assess compliance with the 2012 Existing Edition of the Life Safety Code of the National Fire Protection Association (NFPA) and related reference documents, focusing on emergency preparedness, egress doors, and emergency lighting.
Findings
The facility failed to maintain functioning egress doors and emergency lighting, potentially affecting all residents and staff. Specific issues included fire alarm doors not releasing, emergency lighting not functioning under battery power, and failure to meet NFPA standards for door locks and emergency lighting.
Deficiencies (4)
K222 Egress Doors: The facility failed to maintain functioning egress doors, including a 300 hall unit door that did not release with the fire alarm system. This affected all residents and staff.
K291 Emergency Lighting: The facility failed to maintain functioning emergency lighting, including an emergency light in the main dining room that did not function under battery power. This affected all residents and staff.
A2041 Door Locks: Door locks did not meet regulatory requirements, allowing only one lock per door and requiring unlocking from the inside by turning a knob or operating a simple device.
A2050 Emergency Lighting: Emergency lighting did not meet requirements for sufficient intensity and testing, including battery-operated lights and monthly function tests.
Report Facts
Facility census: 86
Inspection Report
Plan of Correction
Census: 86
Deficiencies: 4
Date: Apr 9, 2021
Visit Reason
The inspection was conducted to assess compliance with federal regulations regarding comprehensive care plans, medication labeling and storage, menu and nutritional adequacy, and food safety in a healthcare facility.
Findings
The facility failed to revise and update comprehensive care plans timely, properly label and store insulin, follow approved menus and recipes, and maintain sanitary food storage and distribution conditions. These deficiencies affected all residents in the facility.
Deficiencies (4)
F657 Comprehensive care plans were not revised or updated for one resident with significant health changes, including cancer diagnosis and gastrostomy tube placement. The care plan did not address recent diagnoses or feeding tube care.
F761 The facility failed to label and store insulin in a safe and effective manner, including undated multi-dose insulin vials in the medication refrigerator. Manufacturer guidelines for insulin discard dates were not followed.
F803 The facility failed to follow approved menus and recipes when preparing and serving food, including serving boiled spinach without recipe approval and using unapproved recipes for pureed meatloaf and spinach. Menu changes were not approved by the registered dietitian.
F812 The facility failed to store and distribute food under sanitary conditions, including uncovered bowls of banana pudding and plates of cake on the meal cart. Dietary staff did not consistently wear hairnets as required by policy.
Report Facts
Facility census: 86
Uncovered bowls of banana pudding: 22
Uncovered plates of cake: 22
Multi-dose insulin vials: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN) | Interviewed regarding insulin vial labeling | |
| Director of Nursing (DON) | Interviewed regarding insulin vial labeling and storage | |
| Cook D | Interviewed regarding food preparation and recipe use | |
| Dietary Manager (DM) | Interviewed regarding menu approval and food safety policies | |
| Administrator | Interviewed regarding care plan and menu oversight |
Inspection Report
Complaint Investigation
Census: 75
Deficiencies: 2
Date: Oct 29, 2020
Visit Reason
The inspection was a COVID-19 focused emergency preparedness survey triggered by a complaint (#MO177266) regarding respiratory care and oxygen administration for a resident with COVID-19 symptoms.
Complaint Details
Complaint #MO177266 was investigated and substantiated based on findings related to inadequate oxygen therapy and respiratory care for a resident diagnosed with COVID-19.
Findings
The facility failed to provide oxygen at the required liter flow with mask application for one resident with COVID-19 related breathing difficulty. Documentation and adherence to oxygen therapy protocols were inadequate, and staff did not consistently assess oxygen therapy effectiveness.
Deficiencies (2)
F695 Respiratory care, including tracheostomy care and suctioning, was deficient as the facility failed to provide oxygen at the required liter flow with mask application for one resident with COVID-19 related breathing difficulty. Documentation of oxygen liter flow and therapy effects was incomplete and inconsistent with facility protocols.
A4074 Each resident shall receive personal attention and nursing care consistent with current acceptable nursing practice. This regulation was not met as evidenced by the respiratory care deficiencies noted in F695.
Report Facts
Facility census: 75
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nurses | Interviewed regarding facility protocol and oxygen therapy procedures | |
| Licensed Practical Nurse (LPN) A | Interviewed about oxygen mask application and monitoring | |
| Licensed Practical Nurse (LPN) C | Interviewed about oxygen liter flow settings | |
| Licensed Practical Nurse (LPN) D | Interviewed about oxygen mask protocol |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Oct 5, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey and complaint investigation were conducted on 10/5/20 to assess compliance with CMS and CDC COVID-19 preparedness requirements.
Complaint Details
The complaint investigation was conducted alongside the COVID-19 Focused Infection Control Survey and the facility was found compliant.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness and with CMS and CDC recommended practices for COVID-19 infection control.
Inspection Report
Abbreviated Survey
Census: 81
Deficiencies: 2
Date: Jun 30, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness survey was conducted to assess infection prevention and control practices related to COVID-19.
Findings
The facility was found to be out of compliance with infection prevention and control requirements, specifically failing to prevent the spread of COVID-19 due to staff not wearing facemasks properly and not maintaining social distancing.
Deficiencies (2)
F880 Infection Control: The facility failed to prevent the development or contain the possible spread of COVID-19 when staff failed to wear facemasks covering their nose and mouth and did not maintain social distancing.
A4085 Infection Control/Communicable Disease: The facility did not meet infection control regulations as evidenced by the F880 deficiency.
Report Facts
Facility census: 81
Employees mentioned
| Name | Title | Context |
|---|---|---|
| HSK A | Housekeeper | Named in observation of improper mask wearing |
| HSK B | Housekeeper | Named in observation of improper mask wearing |
| Nurse Aide D | Certified Nurse Aide | Named in observation of no facemask wearing |
| Director of Education | Director of Education | Interviewed regarding mask policy and social distancing |
| Administrator | Administrator | Interviewed regarding staff mask wearing and positive COVID-19 cases |
| Quality Assurance nurse | Quality Assurance nurse | Interviewed regarding staff mask wearing expectations |
Inspection Report
Abbreviated Survey
Census: 81
Deficiencies: 1
Date: May 28, 2020
Visit Reason
A COVID-19 focused emergency preparedness survey was conducted to assess the facility's infection prevention and control program and compliance with COVID-19 related regulations.
Findings
The facility failed to properly prevent or contain the possible spread of COVID-19 for four residents and staff, with observations of staff and visitors not following mandated infection control policies. The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness.
Deficiencies (1)
F880 Infection Prevention & Control: The facility failed to properly prevent or contain the spread of COVID-19 for four residents and staff by not enforcing mask use and screening protocols for visitors and staff.
Report Facts
Resident census: 81
Compliance with 42 CFR 483.73: 1
Inspection Report
Plan of Correction
Census: 82
Deficiencies: 10
Date: Apr 5, 2019
Visit Reason
The inspection was conducted to assess compliance with federal regulations regarding safe environment, accuracy of assessments, dialysis care, and food safety at Hunter Acres Caring Center.
Findings
The facility was found deficient in maintaining a safe, clean, and homelike environment, accuracy of resident assessments, dialysis care documentation and monitoring, and sanitary food procurement and preparation practices. Multiple specific deficiencies were documented including missing baseboards, inadequate assessment accuracy, failure to monitor dialysis access sites properly, and unsanitary kitchen conditions.
Deficiencies (10)
F 584 Safe/Clean/Comfortable/Homelike Environment. The facility failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior, including missing baseboards and damaged wall coverings in multiple rooms.
F 641 Accuracy of Assessments. The facility failed to ensure the accuracy of assessments for two sampled residents, including incorrect or missing PASARR evaluations.
F 698 Dialysis. The facility failed to provide documentation of ongoing assessments and monitoring for one resident receiving dialysis, including missing orders and failure to check the AV graft site every shift.
F 812 Food Procurement, Store/Prepare/Serve-Sanitary. The facility failed to store, prepare, and serve food under sanitary conditions, including baked-on substances on baking sheets and pans, grease buildup, peeling protective coatings, and dirt and debris on kitchen equipment.
A4029 Communicable Disease-Employees. The facility failed to follow infection control protocols for two employees regarding tuberculosis screening and testing.
A4074 Nursing Care per Resident Condition. Each resident shall receive personal attention and nursing care consistent with current acceptable nursing practice. This was not met as evidenced by deficiencies at F641 and F698.
A6015 Walls/Ceilings/Doors/Windows Clean. Walls and ceilings, including doors, windows and skylights, shall be clean and maintained in good repair. This was not met as evidenced by F584.
A6016 Wall/Ceiling Covering-Sealed & Cleanable. Wall and ceiling covering materials shall be attached and sealed to be easily cleanable. This was not met as evidenced by F584.
A7050 Food Contact Surfaces-Cast Iron/Threads. Food-contact surfaces shall be easily cleanable and free of difficult-to-clean imperfections. This was not met as evidenced by F812.
A7056 Nonfood Contact Surfaces, Cleaning. Surfaces not intended for food contact shall be designed for frequent cleaning and be free of unnecessary ledges and projections. This was not met as evidenced by F812.
Report Facts
Facility census: 82
Opportunities missed to document AV graft assessment: 35
Opportunities to document AV graft assessment: 44
Inspection Report
Life Safety
Census: 82
Deficiencies: 4
Date: Apr 5, 2019
Visit Reason
The inspection was conducted to assess compliance with the 2012 Existing Edition of the Life Safety Code and related fire safety regulations.
Findings
The facility failed to maintain exit egress doors, emergency lighting, kitchen stove hood cleanliness, and proper use of power strips, potentially affecting all residents and staff. Several deficiencies related to door locking arrangements, emergency lighting, cooking facilities, and electrical equipment were cited.
Deficiencies (4)
K222 Egress Doors: The facility failed to maintain exit egress doors as required by NFPA 101. Mechanical release hardware was improperly installed, requiring simultaneous pushing of two hardware sets to open doors.
K291 Emergency Lighting: The facility failed to maintain adequate emergency lighting, including non-functioning emergency lighting in the south side medication room.
K324 Cooking Facilities: The facility failed to maintain the kitchen stove hood free of grease buildup, violating NFPA 101 standards.
K920 Electrical Equipment - Power Cords and Extension Cords: The facility failed to restrict use of power strips and extension cords, with unauthorized use observed in multiple areas.
Report Facts
Facility census: 82
Inspection Report
Annual Inspection
Census: 86
Deficiencies: 15
Date: Jun 15, 2018
Visit Reason
The inspection was an annual survey conducted to assess compliance with federal regulations for Hunter Acres Caring Center, including resident fund management, environment safety, medication administration, food safety, infection control, and pest control.
Findings
The facility was found deficient in multiple areas including availability of petty cash on weekends, housekeeping and maintenance, nurse aide registry checks, medication error rates, food safety practices, infection prevention and control, and pest control. Several residents and employees were interviewed and observations were made to support these findings.
Deficiencies (15)
F 567 Protection/Management of Personal Funds. The facility failed to ensure availability of petty cash on weekends affecting three residents and potentially all residents.
F 584 Safe/Clean/Comfortable/Homelike Environment. The facility failed to maintain a sanitary, orderly, and comfortable interior with multiple missing baseboards and drywall damage in resident rooms.
F 607 Develop/Implement Abuse/Neglect Policies. The facility failed to ensure the Nurse Aide registry was checked for a federal indicator for one employee.
F 759 Free of Medication Error Rates 5 Percent or More. The facility failed to maintain a medication error rate below 5%, with 5 errors in 31 opportunities affecting two residents.
F 812 Food Procurement, Store, Prepare, Serve-Sanitary. The facility failed to store and distribute food under sanitary conditions, including issues with ice machine cleanliness and food labeling.
F 880 Infection Prevention & Control. The facility failed to maintain infection control practices including inadequate cleaning of glucometers and hand sanitizing procedures.
F 925 Maintains Effective Pest Control Program. The facility failed to ensure an effective pest control program, with observations of roaches, spiders, and pest evidence in the kitchen.
A3038 Furniture/Equip, Provide Comfort & Safety. The facility failed to maintain furniture and equipment in good condition as referenced in F 584.
A4054 Safe/Effective Medication System. The facility failed to maintain a safe and effective medication system as referenced in F 759.
A4085 Infection Control/Communicable Disease. The facility failed to use acceptable infection control procedures as referenced in F 880.
A6039 Inspect/Rodent Control. The facility failed to minimize presence of rodents and insects as referenced in F 925.
A7013 Food-Safe, Obtain From Appropriate Sources. The facility failed to obtain and maintain food in sound condition as referenced in F 812.
A7016 Food-Clean Containers, Storage, Covers. The facility failed to store food in clean covered containers as referenced in F 812.
A8023 Develop/Implement A/N Policies. The facility failed to develop and implement abuse/neglect policies as referenced in F 607.
A9002 Resident Fund Use. The facility failed to use resident personal funds exclusively for the resident as referenced in F 567.
Report Facts
Facility census: 86
Medication error opportunities: 31
Medication errors: 5
Medication error rate: 16.13
Sample size for resident funds: 19
Sample size for food safety: 19
Inspection Report
Life Safety
Census: 86
Deficiencies: 11
Date: Jun 15, 2018
Visit Reason
The inspection was conducted to assess compliance with the 2012 edition of the Life Safety Code of the National Fire Protection Association (NFPA) and related fire safety regulations.
Findings
The facility failed to maintain the entire sprinkler system, did not provide monthly inspections of the kitchen hood fire suppression system, and failed to maintain fire rating tags on smoke barrier fire doors. Additional deficiencies included failure to maintain smoke barrier walls, gas-fired equipment ventilation, and combustible decorations not meeting NFPA criteria.
Deficiencies (11)
K353 Sprinkler System - Maintenance and Testing: The facility did not maintain the entire sprinkler system in accordance with NFPA 25, affecting all residents, staff, and occupants in the event of fire.
K355 Portable Fire Extinguishers: The facility failed to provide monthly inspections of the kitchen hood fire suppression system, affecting all residents, staff, and occupants in the event of fire.
K363 Corridor - Doors: The facility failed to maintain fire rating tags on smoke barrier fire doors in corridors throughout the facility, affecting all residents, staff, and occupants in the event of fire.
K372 Subdivision of Building Spaces - Smoke Barrier: The facility failed to maintain smoke barrier walls in smoke zones and high hazard areas, affecting all residents, staff, and occupants in the event of fire.
K522 HVAC - Any Heating Device: The facility failed to maintain gas-fired equipment with intake air from the outside within 18 inches of the floor, affecting all residents, staff, and occupants in the event of fire.
K753 Combustible Decorations: The facility had candles in a resident room and combustible decorations that did not meet NFPA criteria, posing a fire hazard.
A1114 Gas-fired Equipment Requirements: The facility did not comply with NFPA 54 for installation and maintenance of gas-fired equipment.
A2016 Fire Extinguisher UL/FM Monthly Check: The facility failed to maintain documentation and dating of monthly pressure checks for fire extinguishers.
A2034 Sprinkler System-Test/Maintain: The facility did not inspect, maintain, and test sprinkler systems as required for facilities with pre-2007 installations.
A2046 Corridor Requirements: The facility failed to maintain corridors free of obstruction and ensure doors to resident rooms did not swing into corridors.
A2054 Smoke Section Walls/Doors: The facility failed to ensure smoke section walls and doors were properly rated and closed automatically upon fire alarm activation.
Report Facts
Facility census: 86
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