Inspection Reports for
Sikeston Convalescent Center
103 KENNEDY DR, SIKESTON, MO, 63801-5126
Back to Facility ProfileDeficiencies (last 7 years)
Deficiencies (over 7 years)
14.1 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
156% worse than Missouri average
Missouri average: 5.5 deficiencies/yearDeficiencies per year
28
21
14
7
0
Occupancy
Latest occupancy rate
60% occupied
Based on a June 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Plan of Correction
Census: 72
Deficiencies: 3
Date: Jun 5, 2025
Visit Reason
The inspection was conducted to investigate complaints and assess compliance with federal regulations regarding resident notification of changes, incontinence care, and infection prevention and control at Sikeston Convalescent Center.
Complaint Details
Complaint #254888 was investigated related to bowel/bladder incontinence and infection prevention and control. The complaint was substantiated based on observations, interviews, and record reviews.
Findings
The facility failed to notify the designated resident representative of significant changes in condition for one resident, failed to provide appropriate treatment and services for residents with incontinence, and failed to perform proper hand hygiene and incontinence care for two residents. The infection prevention and control program was also deficient in hand hygiene and changing gloves protocols.
Deficiencies (3)
F580 Notify of Changes (Injury/Decline/Room, etc.): The facility failed to notify the designated resident representative/emergency contact for one resident with a significant change in condition.
F690 Bowel/Bladder Incontinence, Catheter, UTI: The facility failed to ensure two residents received appropriate treatment and services after incontinence episodes, including proper hygiene and timely changing of briefs.
F880 Infection Prevention & Control: The facility failed to perform hand hygiene, change gloves, and provide appropriate incontinence care for two residents, violating infection control standards.
Report Facts
Resident census: 72
Number of sampled residents with deficiencies: 3
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
Annual Inspection
Census: 66
Deficiencies: 9
Date: Jan 13, 2025
Visit Reason
The inspection was an annual survey conducted to assess compliance with federal regulations for Sikeston Convalescent Center.
Findings
The facility was found deficient in multiple areas including documentation of code status for residents, maintenance of a safe and comfortable environment, baseline care planning, pharmacy services including narcotic reconciliation, psychotropic medication use, medication error rates, food safety, infection control, and proper disposal of garbage and refuse.
Deficiencies (9)
F578 Request/Refuse/Discontinue Treatment; Formulate Advance Directive. The facility failed to document a code status for one resident outside the sample of 17 residents.
F584 Safe/Clean/Comfortable/Homelike Environment. The facility failed to monitor and keep one resident's equipment in good working order and failed to provide a safe, clean, and comfortable home-like environment.
F655 Baseline Care Plan. The facility failed to develop and implement a baseline care plan within 48 hours of admission for one resident outside the sample.
F755 Pharmacy Services/Procedures/Pharmacist/Records. The facility failed to ensure staff reconciled narcotics at each shift change for five medication carts.
F758 Free from Unnecessary Psychotropic Medications/PRN Use. The facility failed to ensure an appropriate diagnosis for the use of psychotropic medication for one resident out of five sampled residents.
F759 Free of Medication Error Rates 5 Percent or More. The facility failed to maintain a medication error rate of less than 5 percent, with an error rate of 7.41% for two residents.
F812 Food Procurement, Store, Prepare, Serve, Sanitary. The facility failed to store and distribute food under sanitary conditions, increasing the risk of cross-contamination and food-borne illness.
F814 Dispose Garbage and Refuse Properly. The facility failed to ensure dumpsters were closed and maintained to keep pests out and prevent garbage exposure.
F880 Infection Prevention & Control. The facility failed to implement Enhanced Barrier Precautions during wound care and failed to post EBP signage outside residents' rooms.
Report Facts
Facility census: 66
Medication error rate: 7.41
Medication cart narcotic reconciliation failures: 5
Missed narcotic reconciliation opportunities: 27
Inspection Report
Life Safety
Census: 66
Deficiencies: 3
Date: Jan 13, 2025
Visit Reason
The inspection was conducted to assess compliance with the Life Safety Code and related fire safety regulations at Sikeston Convalescent Center.
Findings
The facility failed to maintain the kitchen hood in a safe, functioning state, maintain trash and smoking bins properly, and restrict the use of temporary wiring. These deficiencies potentially affected all residents and staff.
Deficiencies (3)
K324 Cooking Facilities: The facility failed to maintain the kitchen hood in a safe, functioning state, with two-inch gaps between baffles allowing grease buildup in the vent hood.
K741 Smoking Regulations: The facility failed to maintain the trash and smoking bins, with the cigarette butt container full of combustible trash and cigarette butts.
K920 Electrical Equipment - Power Cords and Extension Cords: The facility failed to restrict the use of temporary wiring, with a microwave plugged into a power strip in the Director of Nurses' office.
Report Facts
Facility census: 66
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: 3
Date: Aug 14, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding failure to notify a resident's family/responsible party about an injury sustained during a transfer, resulting in a fractured femur.
Complaint Details
Complaint #MO00240456 was substantiated. The facility failed to notify the resident's family/responsible party of the injury and hospital transfer related to a left leg fracture sustained during a transfer.
Findings
The facility failed to notify the resident's family/responsible party in a timely manner after the resident's left leg became entangled in a wheelchair during transfer, causing injury. The facility also failed to provide a safe transfer per policy, resulting in a left femur fracture for one resident.
Deficiencies (3)
F580 Notification of Changes: The facility failed to notify the resident's family/responsible party after the resident's left leg was injured during transfer and subsequent hospital admission. The facility lacked a policy regarding notification guidelines.
F689 Free of Accident Hazards/Supervision/Devices: The facility failed to provide a safe transfer per policy, resulting in a resident's left femur fracture and loss of ability to bear weight on the leg. The facility did not ensure adequate supervision and assistance to prevent accidents.
A4088 Notify Responsible Party-Change in Condition: The facility failed to notify the responsible party of the resident's injury and change in condition as required by regulation.
Report Facts
Resident census: 66
Sampled residents: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse D | Registered Nurse | Mentioned in relation to assessment of resident's injury and hospital transfer |
| Licensed Practical Nurse C | Licensed Practical Nurse | Mentioned regarding notification procedures and incident reporting |
| Director of Nursing | Director of Nursing | Mentioned in relation to incident documentation and notification |
| Administrator | Administrator | Mentioned regarding expectations for family notification |
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
Annual Inspection
Census: 74
Deficiencies: 8
Date: Dec 15, 2023
Visit Reason
The inspection was conducted as an annual survey of Sikeston Convalescent Center to assess compliance with federal and state regulations.
Findings
The facility was found deficient in maintaining the surety bond for residents' personal funds and failed to provide a safe, clean, comfortable, and homelike environment due to multiple maintenance issues. Additionally, the facility did not complete timely comprehensive assessments, quarterly assessments, and discharge planning processes for several residents.
Deficiencies (8)
F570 Surety Bond-Security of Personal Funds: The facility failed to maintain the surety bond amount at one and one-half times the average monthly balance of residents' personal funds for the last twelve consecutive months.
F584 Safe/Clean/Comfortable/Homelike Environment: The facility failed to provide a safe, clean, comfortable, and homelike environment as evidenced by broken mini blinds, exposed sheetrock, peeled paint, scuff marks, and debris in multiple areas.
F636 Comprehensive Assessments & Timing: The facility failed to ensure a comprehensive Minimum Data Set (MDS) assessment was completed timely for one resident and one resident was outside the sample.
F637 Comprehensive Assessment After Significant Change: The facility failed to complete a significant change MDS assessment within 14 days for one resident admitted to hospice.
F638 Quarterly Assessment at Least Every 3 Months: The facility failed to complete timely quarterly MDS assessments for 15 residents outside the sample.
F658 Services Provided Meet Professional Standards: The facility failed to obtain a physician's order for medication, oxygen, BiPAP, and indwelling urinary catheter care for one resident.
F660 Discharge Planning Process: The facility failed to ensure a discharge planning process was in place that addressed goals, needs, and involved the resident and interdisciplinary team for one resident.
F661 Discharge Summary: The facility failed to complete a comprehensive discharge summary for one resident who left against medical advice.
Report Facts
Facility Census: 74
Residents with untimely MDS assessments: 15
Residents sampled for MDS assessment: 18
Residents with significant change MDS assessment deficiency: 1
Residents with discharge planning deficiency: 1
Residents with discharge summary deficiency: 1
Inspection Report
Life Safety
Deficiencies: 2
Date: Dec 15, 2023
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 emergency preparedness and fire safety regulations.
Findings
The facility failed to maintain exit illumination in case of emergency and failed to perform required quarterly fire drills on each shift. These deficiencies potentially affected all residents and staff.
Deficiencies (2)
K281 Illumination of Means of Egress: The facility failed to maintain exit illumination in case of emergency, affecting all residents and staff. Observation showed no continuous emergency illumination in the smoking courtyard during power outage or emergency.
K712 Fire Drills: The facility failed to perform fire drills on each shift, quarterly and at varying times and conditions. Documentation showed no fire drills completed for several months, affecting all residents and staff in the event of a fire.
Report Facts
Facility census: 74
Facility census: 20
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Maintenance | Interviewed regarding fire drills and department oversight | |
| Maintenance Supervisor | Interviewed regarding emergency lighting and plan of correction |
Inspection Report
Plan of Correction
Census: 66
Deficiencies: 2
Date: Jan 10, 2023
Visit Reason
The inspection was conducted to assess compliance with professional standards of care, specifically regarding wound care and comprehensive care plans for residents.
Findings
The facility failed to provide adequate follow-up wound care and physician notification for a resident with a surgical wound. Documentation and monitoring of the surgical site were insufficient, and the resident subsequently passed away due to complications.
Deficiencies (2)
F658 Services Provided Meet Professional Standards CFR(s): 483.21(b)(3)(i) The facility failed to assess, provide follow-up wound care, and contact a physician for orders regarding a surgical wound for one resident. Documentation of wound care and monitoring was incomplete and inconsistent.
A4074 19 CSR 30-85.042(67) Nursing Care per Res Condition Each resident shall receive personal attention and nursing care consistent with current acceptable nursing practice. This regulation was not met as evidenced by the deficiency referenced in F658.
Report Facts
Facility census: 66
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 |
Inspection Report
Annual Inspection
Census: 74
Deficiencies: 16
Date: Jun 30, 2022
Visit Reason
The inspection was an annual survey conducted to assess compliance with federal and state regulations for the Sikeston Convalescent Center.
Findings
The facility was found deficient in multiple areas including personal funds management, Medicaid/Medicare coverage notices, quarterly resident assessments, comprehensive care plans, respiratory care, nurse aide training, food safety, and communicable disease employee screening. Several residents' funds were not refunded timely, care plans were incomplete or not updated, and infection control and safety protocols were not fully met.
Deficiencies (16)
F569 Notice and Conveyance of Personal Funds: The facility failed to refund resident funds within 30 days of discharge or death for multiple residents and did not notify residents receiving Medicaid benefits when account balances reached the SSI resource limit.
F582 Medicaid/Medicare Coverage/Liability Notice: The facility failed to provide timely Notice of Medicare Non-Coverage (NOMNC) and Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) forms to a resident at least two calendar days before Medicare services ended.
F638 Quarterly Assessment at Least Every 3 Months: The facility failed to complete federally mandated quarterly Minimum Data Set (MDS) assessments within required timeframes for multiple residents.
F656 Develop/Implement Comprehensive Care Plan: The facility failed to develop and implement individualized comprehensive care plans with measurable objectives and timeframes for multiple residents.
F657 Care Plan Timing and Revision: The facility failed to develop comprehensive care plans within 7 days of assessment completion and did not revise care plans after significant changes for multiple residents.
F695 Respiratory/Tracheostomy Care and Suctioning: The facility failed to obtain physician orders for oxygen use and did not ensure oxygen tubing did not touch the floor for residents needing respiratory care.
F730 Nurse Aide Perform Review-12 hr/yr In-Service: The facility failed to provide required annual competencies for one certified nursing assistant out of two sampled.
F812 Food Procurement, Store/Prepare/Serve-Sanitary: The facility failed to store, prepare, distribute, and serve food under sanitary conditions, including issues with food labeling, storage, and equipment cleanliness.
A4031 Communicable Disease-Employees: The facility failed to ensure employees were screened for tuberculosis with required testing intervals and documentation.
A40105 Medical Record-Physician Documentation: The facility failed to include physician entries in medical records as required, including admission diagnosis and treatment orders.
A7015 Food-Protected, Temp, Need to Contact DHSS: The facility failed to protect food from contamination and maintain required temperatures during storage and handling.
A7087 Protect Equipment/Utensils From Contamination: The facility failed to clean and sanitize equipment and utensils to prevent contamination.
A8004 Resident Rights-Admission/Annual Review: The facility failed to fully inform residents or their representatives of rights and responsibilities annually.
A8013 Right to Plan Care/Refuse Treatment: The facility failed to afford residents the opportunity to participate in care planning and document refusals of treatment.
A9010 Discharge Requirement Within 5 Days: The facility failed to provide timely accounting and return of resident funds and possessions within five days of discharge.
A9011 Death of Resident, Contact DSS: The facility failed to document contact with the Department of Social Services upon resident death as required.
Report Facts
Facility census: 74
Residents with delayed fund refunds: 15
Residents sampled for MDS assessments: 18
Nurse aides sampled: 2
Employees screened for TB: 10
Food prep equipment pieces: 58
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse I | Licensed Practical Nurse | Named in communicable disease screening deficiency for TB testing |
| Dietary Aide M | Dietary Aide | Named in communicable disease screening deficiency for TB testing |
| Director of Nursing | Director of Nursing | Interviewed regarding care plan revisions and TB testing |
| Business Office Manager | Business Office Manager | Interviewed regarding resident funds and notifications |
| Social Services Designee | Social Services Designee | Interviewed regarding Medicare notification forms |
| Administrator | Administrator | Signed plan of correction and interviewed regarding MDS and resident funds |
| Licensed Practical Nurse (LPN) | Licensed Practical Nurse | Interviewed regarding oxygen tubing and equipment |
| Dietary Aide (DA) K | Dietary Aide | Observed during food handling and sanitation review |
| Director of Nursing (DON) | Director of Nursing | Interviewed regarding oxygen therapy and care plans |
| Quality Assurance Nurse | Quality Assurance Nurse | Interviewed regarding oxygen therapy and care plans |
Inspection Report
Life Safety
Census: 74
Deficiencies: 4
Date: Jun 29, 2022
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 adequate exit illumination and sprinkler coverage, which potentially affected all residents and staff. Emergency egress lighting was not operational and sprinkler coverage was missing at certain entrances.
Deficiencies (4)
K281 Illumination of Means of Egress: The facility failed to maintain adequate exit illumination along the exit egress pathways, with no emergency egress lighting observed at Autumn Court.
K353 Sprinkler System - Maintenance and Testing: The facility failed to maintain adequate sprinkler coverage, with missing sprinkler coverage at the A Hall Physical Therapy entrance door and rear employee entrance.
A2035 Complete Sprinkler System: The facility did not meet the requirement to install and maintain a complete sprinkler system in accordance with NFPA 13, 1999 edition.
A2050 Emergency Lighting: The facility failed to provide emergency lighting of sufficient intensity for safety, including automatic emergency generator or battery lighting system.
Report Facts
Facility census: 74
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Mar 17, 2021
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted in conjunction with a complaint investigation to assess compliance with CMS and CDC recommended practices for COVID-19.
Complaint Details
The visit was complaint-related and the facility was found to be in compliance with no deficiencies cited.
Findings
The facility was found to be in compliance with 42 CFR 483.73 and CDC recommended practices for COVID-19. No deficiencies were cited as a result of this onsite visit.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jan 6, 2021
Visit Reason
A COVID-19 Focused Infection Control Survey and complaint investigation were conducted onsite to assess compliance with CMS and CDC recommended practices for COVID-19 preparedness and infection control.
Complaint Details
The complaint investigation was related to COVID-19 infection control practices and was found to be unsubstantiated as no deficiencies were cited.
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. No deficiencies were cited as a result of this onsite visit.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Jun 19, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control Survey was conducted to assess the facility's compliance with relevant regulations and CDC recommended practices.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness and with CMS and CDC recommended infection control practices for COVID-19.
Inspection Report
Annual Inspection
Census: 72
Deficiencies: 9
Date: Jan 9, 2020
Visit Reason
Annual inspection of Sikeston Convalescent Center to assess compliance with federal regulations and state requirements.
Findings
The facility was found deficient in multiple areas including preparation and orientation for transfer or discharge, accuracy of assessments, development and implementation of comprehensive care plans, infection prevention and control, use of restraints, and provision of adequate care for residents with specific needs.
Deficiencies (9)
F624 Preparation for Safe/Orderly Transfer/Discharge: The facility failed to document sufficient preparation and orientation for transfer to the hospital for seven residents.
F641 Accuracy of Assessments: The facility failed to ensure the accuracy of assessments for two residents, including documentation of falls and health conditions.
F656 Develop/Implement Comprehensive Care Plan: The facility failed to implement individualized comprehensive care plans for four residents, lacking measurable objectives and timely updates.
F657 Care Plan Timing and Revision: The facility failed to revise and update comprehensive care plans with specific interventions for nine residents.
F658 Services Provided Meet Professional Standards: The facility failed to obtain physician's orders for use of restraints and hospice care for two residents.
F677 ADL Care Provided for Dependent Residents: The facility failed to provide assistance with personal hygiene for one resident.
F685 Treatment/Devices to Maintain Hearing/Vision: The facility failed to ensure proper treatment to maintain hearing ability for one resident.
F689 Free of Accident Hazards/Supervision/Devices: The facility failed to prevent accidents and falls for three residents, including inadequate supervision and interventions.
F880 Infection Prevention & Control: The facility failed to establish and maintain an infection prevention and control program, including hand hygiene and cleaning protocols, for multiple residents.
Report Facts
Residents sampled: 19
Residents with deficiencies: 7
Facility census: 72
Inspection Report
Life Safety
Deficiencies: 0
Date: Jan 9, 2020
Visit Reason
The inspection was conducted to assess compliance with the Life Safety Code and to perform a licensure inspection of Sikeston Convalescent Center.
Findings
No deficiencies were cited during the Emergency Preparedness portion or the licensure inspection. The facility met the applicable provisions of the 2012 edition of the Life Safety Code.
Inspection Report
Annual Inspection
Census: 74
Deficiencies: 5
Date: Oct 18, 2018
Visit Reason
The inspection was conducted as an annual survey to assess compliance with federal regulations for the Sikeston Convalescent Center.
Findings
The facility was found deficient in several areas including failure to notify residents and representatives of transfers, incomplete comprehensive care plans, inadequate infection control practices, and lack of an antibiotic stewardship program. Multiple residents were affected by these deficiencies.
Deficiencies (5)
F623: The facility failed to notify residents and their representatives in writing of transfers to the hospital for four out of 18 sampled residents. No documentation of transfer notices was found for Residents #2, #3, #16, and #56.
F656: The facility failed to develop and implement comprehensive, person-centered care plans with measurable objectives and interventions for four residents. Care plans did not address fracture care, oxygen use, medication administration, or skin condition related to braces.
F880: The facility failed to maintain an effective infection prevention and control program. Observations showed improper cleaning of glucometers and inadequate hand hygiene by staff, contributing to infection risk for residents.
F881: The facility failed to implement an antibiotic stewardship program including protocols for antibiotic use review and feedback. The facility lacked a policy for antibiotic stewardship and missed components in monitoring antibiotic use.
A4085: The facility failed to report communicable diseases to the Missouri Department of Health within seven days as required by state regulations.
Report Facts
Resident census: 74
Sampled residents: 18
Residents transferred without notice: 4
Residents affected by infection control deficiency: 4
Residents receiving antibiotics: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kimberly Chin | Administrator | Signed plan of correction and mentioned in interviews regarding infection control and antibiotic stewardship |
| Director of Nursing | Interviewed regarding transfer notices, care plans, infection control, and antibiotic stewardship | |
| Social Services Director | Mentioned in plan of correction regarding transfer notification | |
| RN A | Registered Nurse | Observed providing care and interviewed about infection control practices |
| RN E | Registered Nurse | Observed and interviewed regarding glove use and infection control |
| Certified Medication Tech D | Interviewed about medication administration |
Inspection Report
Life Safety
Census: 74
Deficiencies: 5
Date: Oct 16, 2018
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) 101 and related fire safety regulations.
Findings
The facility failed to maintain battery-operated exit illumination, adequate exit signage, required separation of hazardous areas, monthly inspections of fire extinguishers, and proper operation of fire doors. These deficiencies potentially affected all residents and staff.
Deficiencies (5)
K281: The facility failed to maintain battery-operated exit illumination leading to the public way, affecting all residents and staff.
K293: The facility failed to have adequate exit signage, including no exit sign posted at the central courtyard gate.
K321: The facility failed to maintain required separation of hazardous areas, including a blocked rolling kitchen window door.
K355: The facility failed to maintain monthly inspections of fire extinguishers, including an uninspected ANSUL pull station and a damaged fire extinguisher.
K363: The facility failed to maintain fire doors to release when the fire alarm was activated, including doors held open by door stops and a door that did not release during testing.
Report Facts
Facility census: 74
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