Inspection Reports for
Sikeston Convalescent Center
103 KENNEDY DR, SIKESTON, MO, 63801-5126
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
7.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
36% worse than Missouri average
Missouri average: 5.5 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
72 residents
Based on a June 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Occupancy over time
Inspection Report
Complaint Investigation
Census: 72
Deficiencies: 3
Date: Jun 5, 2025
Visit Reason
The inspection was conducted in response to Complaint #254888 regarding failure to notify a resident's designated representative of a significant change in condition and concerns about incontinent care and infection control practices.
Complaint Details
Complaint #254888 involved failure to notify the resident representative of a significant change in condition and inadequate incontinent care and infection control practices for residents #1, #4, and #5.
Findings
The facility failed to notify the designated resident representative of a significant change in condition for one resident and failed to provide appropriate incontinent care and infection prevention practices for two residents who were incontinent of bladder. Observations and interviews revealed inadequate notification, incomplete cleaning during incontinent care, and failure to change gloves and perform hand hygiene between dirty and clean tasks.
Deficiencies (3)
Failure to notify the resident's designated representative of a significant change in condition.
Failure to provide appropriate treatment and services after incontinent episodes, leaving residents in urine saturated briefs with strong urine odor.
Failure to perform hand hygiene, change gloves, and provide appropriate incontinent care, including cleaning all soiled areas.
Report Facts
Residents affected: 1
Residents affected: 2
Facility census: 72
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CMT D | Certified Medication Technician | Notified nurse of resident's unresponsiveness |
| LPN F | Licensed Practical Nurse | Assessed resident and notified EMS |
| LPN G | Licensed Practical Nurse | Assisted LPN F in resident assessment |
| RN E | Registered Nurse | Interviewed about notification procedures |
| Director of Nursing | Director of Nursing | Interviewed about notification and incontinent care policies |
| Administrator | Administrator | Interviewed about family notification during resident transfer |
| CNA B | Certified Nurse Aide | Observed providing incontinent care and interviewed about care practices |
| Infection Preventionist | Infection Preventionist | Interviewed about infection control practices during incontinent care |
Inspection Report
Routine
Census: 66
Deficiencies: 9
Date: Jan 13, 2025
Visit Reason
The inspection was a routine regulatory visit to assess compliance with healthcare facility standards, including resident rights, care planning, medication management, environment, infection control, and food safety.
Findings
The facility had multiple deficiencies including failure to document resident code status, incomplete baseline care plans within 48 hours of admission, inadequate narcotic reconciliation, inappropriate psychotropic medication use without proper diagnosis, medication administration errors, unsanitary food storage and preparation conditions, improper garbage disposal, and failure to implement enhanced barrier precautions during wound care.
Deficiencies (9)
Failed to document a code status for one resident (Resident #9).
Failed to monitor and keep one resident's equipment in good, working order and provide a safe, clean, comfortable homelike environment.
Failed to develop and implement a baseline care plan within 48 hours of admission for one resident (Resident #9).
Failed to ensure staff reconciled narcotics at each shift change for five medication carts.
Failed to ensure an appropriate diagnosis for the use of a psychotropic medication for one resident (Resident #45).
Failed to maintain a medication error rate of less than 5%, with 2 errors in 27 opportunities for two residents.
Failed to store and distribute food under sanitary conditions, including unsealed, unlabeled, and expired food items and unsanitary kitchen equipment.
Failed to ensure dumpsters were closed at all times and maintained to keep pests out and garbage contained.
Failed to implement Enhanced Barrier Precautions during wound care for multiple residents, including failure to wear gowns and post signage.
Report Facts
Facility census: 66
Medication error rate: 7.41
Narcotic reconciliation missed opportunities: 11
Narcotic reconciliation missed opportunities: 13
Narcotic reconciliation missed opportunities: 20
Narcotic reconciliation missed opportunities: 9
Narcotic reconciliation missed opportunities: 20
Narcotic reconciliation missed opportunities: 12
Narcotic reconciliation missed opportunities: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN B | Licensed Practical Nurse | Named in multiple wound care findings related to failure to implement enhanced barrier precautions |
| LPN F | Licensed Practical Nurse | Named in medication administration errors related to insulin pen use |
| Director of Nursing | Interviewed regarding expectations for code status documentation, baseline care plans, narcotic reconciliation, psychotropic medication use, insulin administration, and infection control | |
| Administrator | Interviewed regarding expectations for code status documentation, baseline care plans, narcotic reconciliation, food safety, and garbage disposal | |
| Assistant Dietary Manager | Interviewed regarding food storage, kitchen sanitation, and dumpster lid closure | |
| Dietary Manager | Interviewed regarding food storage, kitchen sanitation, and dumpster lid closure | |
| Maintenance Supervisor | Interviewed regarding maintenance of grounds and dumpster lid closure | |
| Certified Medication Technician C | Interviewed regarding medication administration and narcotic reconciliation | |
| Corporate Nurse | Interviewed regarding narcotic reconciliation and infection control expectations | |
| Housekeeper A | Interviewed regarding maintenance log and dumpster lid closure |
Inspection Report
Complaint Investigation
Census: 66
Deficiencies: 2
Date: Aug 14, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding failure to notify a resident's family in a timely manner after an injury during transfer and failure to provide a safe transfer resulting in a fractured femur for Resident #1.
Complaint Details
Complaint #MO00240456 regarding failure to notify family and unsafe transfer resulting in injury to Resident #1.
Findings
The facility failed to notify the resident's family/responsible party timely after the resident's left leg became entangled in a wheelchair causing pain and subsequent injury, and after transfer to the hospital for a fractured femur. The facility also failed to provide a safe transfer per policy, as a single nurse aide attempted a two-person transfer, causing the injury. The incident was not properly reported or monitored by staff.
Deficiencies (2)
Failure to notify resident's family/responsible party in a timely manner after injury and hospital transfer.
Failure to provide a safe transfer per facility policy resulting in resident injury (fractured femur) and immediate jeopardy to resident health or safety.
Report Facts
Residents affected: 1
Facility census: 66
Date of incident: Aug 2, 2024
Date survey completed: Aug 14, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| NA A | Nurse Aide | Involved in unsafe transfer causing resident injury |
| CNA B | Certified Nurse Aide | Assisted in transfer and reported incident to DON |
| Director of Nursing (DON) | Director of Nursing | Conducted late entry note and interviews; failed to ensure family notification and proper incident reporting |
| LPN C | Licensed Practical Nurse | Assessed resident post-incident; not notified timely of injury |
| RN D | Registered Nurse | Assessed resident and sent to hospital; failed to notify family |
| LPN E | Licensed Practical Nurse | Provided care post-incident; not initially aware of injury |
| CNA Instructor | CNA Instructor | Provided orientation and training on resident handling |
| Nurse Practitioner (NP) | Nurse Practitioner | Notified post-incident; would have ordered x-ray if aware |
| Administrator | Facility Administrator | Expected proper notification and reporting of incident |
Inspection Report
Routine
Census: 74
Deficiencies: 8
Date: Dec 15, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements including security of residents' personal funds, environmental safety, timely completion of Minimum Data Set (MDS) assessments, medication and treatment orders, discharge planning, and discharge summary documentation.
Findings
The facility was found deficient in maintaining an adequate surety bond for residents' personal funds, providing a safe and homelike environment, completing timely MDS assessments including comprehensive, significant change, and quarterly MDS, obtaining physician orders prior to medication and treatment administration, and ensuring proper discharge planning and discharge summary documentation. All deficiencies were cited with minimal harm or potential for actual harm to residents.
Deficiencies (8)
Failed to maintain surety bond at one and one-half times the average monthly balance of residents' personal funds.
Failed to provide a safe, clean, comfortable and homelike environment with multiple areas of broken blinds, exposed sheetrock, peeled paint, scuff marks, debris, and spider webs.
Failed to complete comprehensive Minimum Data Set (MDS) assessments in a timely manner for two residents.
Failed to complete significant change MDS assessment within 14 days of resident admission to hospice.
Failed to complete quarterly MDS assessments in a timely manner for 15 residents.
Failed to obtain physician's orders for medication, oxygen, BiPAP machine, and indwelling urinary catheter prior to administration for one resident.
Failed to ensure discharge planning process addressed resident goals and needs involving resident/legal guardian and interdisciplinary team for one discharged resident.
Failed to complete a comprehensive discharge summary for one discharged resident.
Report Facts
Facility census: 74
Surety bond amount: 66000
Average monthly balance: 50558.82
Required bond amount: 76500
Number of residents with late quarterly MDS: 15
Number of residents sampled for MDS timeliness: 18
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Business Office Manager | Business Office Manager | Interviewed regarding surety bond requirements |
| Administrator | Administrator | Interviewed regarding surety bond, MDS completion, medication orders, discharge planning, and discharge summary expectations |
| Certified Nurse Assistant A | Certified Nurse Assistant | Interviewed regarding reporting environmental concerns |
| Assistant Maintenance Supervisor | Assistant Maintenance Supervisor | Interviewed regarding maintenance log procedures |
| Maintenance Supervisor | Maintenance Supervisor | Interviewed regarding maintenance reporting and repairs |
| Housekeeping Supervisor | Housekeeping Supervisor | Interviewed regarding environmental concerns reporting |
| MDS Coordinator | MDS Coordinator | Interviewed regarding MDS completion timeliness |
| Director of Nursing | Director of Nursing | Interviewed regarding MDS completion, medication orders, and discharge planning |
| Social Service Director | Social Service Director | Interviewed regarding discharge planning and discharge summary |
Inspection Report
Routine
Census: 74
Deficiencies: 8
Date: Jun 30, 2022
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident funds management, notification of Medicare non-coverage, Minimum Data Set (MDS) assessments, care planning, respiratory care, staff training, and food safety.
Findings
The facility failed to refund resident funds within 30 days of discharge or death for multiple residents, failed to provide timely Notice of Medicare Non-Coverage and Skilled Nursing Facility Advanced Beneficiary Notice, did not complete quarterly MDS assessments within required timeframes for several residents, failed to develop and update individualized care plans with specific interventions, failed to obtain physician orders and maintain proper oxygen equipment care for residents on oxygen, failed to provide required annual competencies training for a certified nursing assistant, and failed to maintain sanitary food storage, preparation, and serving conditions.
Deficiencies (8)
Failed to refund resident funds within 30 days of discharge or death for multiple residents and failed to send spend down notification letter.
Failed to provide Notice of Medicare Non-Coverage and Skilled Nursing Facility Advanced Beneficiary Notice at least two calendar days before services ended for one resident.
Failed to complete quarterly Minimum Data Set (MDS) assessments within required timeframes for multiple residents.
Failed to develop and implement individualized comprehensive care plans with specific interventions for residents.
Failed to update and revise care plans with specific interventions tailored to meet individual needs after falls for residents.
Failed to obtain physician orders for oxygen use, failed to date oxygen tubing and humidifier bottles, and failed to ensure oxygen tubing did not touch the floor for residents on oxygen therapy.
Failed to provide required annual competencies training on abuse prevention and dementia care for one certified nursing assistant.
Failed to store, prepare, distribute, and serve food under sanitary conditions, including ungloved handling of cups and ice, unlabeled and undated food items, and kitchen equipment with carbon and grime build-up.
Report Facts
Facility census: 74
Resident funds amounts: 11245.43
Resident funds amounts: 4391.26
Resident funds amounts: 150.58
Resident funds amounts: 511.43
Resident funds amounts: 2442.28
Resident funds amounts: 10.73
Resident funds amounts: 63
Resident funds amounts: 1230.01
Resident funds amounts: 4
Resident funds amounts: 8
Resident funds amounts: 620.28
Resident funds amounts: 150.13
Resident funds amounts: 6.02
Resident funds amounts: 310.04
Resident funds amounts: 50.19
Resident funds amounts: 43.41
Resident funds amounts: 114.05
Resident funds amounts: 10.5
Resident funds amounts: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA H | Certified Nursing Assistant | Failed to receive annual competencies training on abuse prevention |
| Business Office Manager | Business Office Manager | Interviewed regarding resident funds and notifications |
| Social Services Designee | Social Services Designee | Interviewed regarding Notice of Medicare Non-Coverage and Skilled Nursing Facility Advanced Beneficiary Notice |
| Director of Nursing | Director of Nursing | Interviewed regarding care plans, oxygen therapy, and staff training |
| MDS Coordinator | MDS Coordinator | Interviewed regarding MDS assessments |
| Licensed Practical Nurse I | Licensed Practical Nurse | Interviewed regarding oxygen tubing and care |
| Dietary Aide K | Dietary Aide | Observed handling food and drinks unsafely |
| Dietary Aide L | Dietary Aide | Interviewed regarding safe food handling practices |
| Dietary Manager | Dietary Manager | Interviewed regarding food storage and kitchen equipment sanitation |
| Quality Assurance Nurse | Quality Assurance Nurse | Interviewed regarding care plans and oxygen therapy |
| Administrator | Administrator | Interviewed regarding MDS assessments and food safety |
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