Sikeston, MO

Delta South Nursing & Rehabilitation

4-star overall rating with 4-star inspections with 9 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle

640 Colonel George E Day Parkway, Sikeston, MO

(573) 471-3400

Compare this facility

Overall

4 / 5

CMS overall stars

Health inspections

4 / 5

Survey and complaint cycles

Staffing

3 / 5

RN + nurse staffing

Quality measures

4 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

Certified beds

Average residents

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

No chain reported

Operator or chain grouping

Approved since

2017-08-16

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Changed ownership

Within the last 12 months

Family council

Yes

Resident and family council reported

Sprinklers

Yes

Automatic sprinklers in all required areas

Staffing

Hours and turnover

RN hours / resident day

0.42

Registered nurse staffing · state 0.46 · national 0.68

LPN hours / resident day

0.38

Licensed practical nurse staffing · state 0.68 · national 0.87

Aide hours / resident day

2.34

Nurse aide staffing · state 2.33 · national 2.35

Total nurse hours

3.14

All reported nurse hours · state 3.47 · national 3.89

Licensed hours

0.80

RN + LPN hours · state 1.14 · national 1.54

Weekend hours

2.86

Weekend nurse staffing · state 3.04 · national 3.43

Weekend RN hours

0.50

Weekend registered nurse coverage · state 0.33 · national 0.47

Physical therapist

0.03

Reported PT staffing · state 0.05 · national 0.07

Adjusted RN hours

0.52

CMS adjusted RN staffing hours

Adjusted total hours

3.89

CMS adjusted total nurse staffing hours

Case-mix index

1.10

Higher values indicate more complex resident acuity

RN turnover

17%

Annual RN turnover · state 51% · national 45%

Total nurse turnover

51%

Annual nurse turnover · state 57% · national 46%

SNF VBP

Value-based purchasing

Program rank

12,927

Lower is better among SNFs in the FY 2026 VBP program.

Performance score

9.58

Composite VBP score used to determine payment impact.

Payment multiplier

0.9808

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

1.73

Baseline 21.09% · Performance 20.63% · Measure score 1.73 · Achievement 1.73 · Improvement 0.64

Healthcare-associated infections

2.10

Baseline 8.18% · Performance 7.35% · Measure score 2.10 · Achievement 1.61 · Improvement 2.10

Total nurse turnover

Performance 62.50% · Measure score 0 · Achievement 0 · This facility did not have sufficient data to calculate a baseline period measure result.

Adjusted total nurse staffing

Baseline 3.39 hours · Performance 3.12 hours · Measure score 0 · Achievement 0 · Improvement 0

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	11.41%	10.72% 0.7 pts worse	No Different than the National Rate · Eligible stays 111 · Observed rate 12.61% · Lower 95% interval 7.29%
Discharge to community	54.42%	50.57% 3.9 pts better	No Different than the National Rate · Eligible stays 94 · Observed rate 48.94% · Lower 95% interval 45.9%
Medicare spending per beneficiary	1.14	1.02 0.1 pts worse
Drug regimen review with follow-up	90%	95.27% 5.3 pts worse	Numerator 45 · Denominator 50
Falls with major injury	0%	0.77% 0.8 pts better	Numerator 0 · Denominator 50
Discharge self-care score	71.43%	53.69% 17.7 pts better	Numerator 25 · Denominator 35
Discharge mobility score	71.43%	50.94% 20.5 pts better	Numerator 25 · Denominator 35
Pressure ulcers or injuries, new or worsened	0%	2.29% 2.3 pts better	Numerator 0 · Denominator 50 · Adjusted rate 0%
Healthcare-associated infections requiring hospitalization	7.35%	7.12% 0.2 pts worse	No Different than the National Rate · Eligible stays 79 · Observed rate 7.59% · Lower 95% interval 4.33%
Staff COVID-19 vaccination coverage	5.88%	8.2% 2.3 pts worse	Numerator 5 · Denominator 85
Staff flu vaccination coverage	0.86%	42% 41.1 pts worse	Numerator 1 · Denominator 116
Discharge function score	82.86%	56.45% 26.4 pts better	Numerator 29 · Denominator 35
Transfer of health information to provider	Not Available	95.95%	Numerator Not Available · Denominator 10 · Too few residents or stays to report publicly.
Transfer of health information to patient	100%	96.28% 3.7 pts better	Numerator 40 · Denominator 40
Resident COVID-19 vaccinations up to date	4.35%	25.2% 20.9 pts worse	Numerator 1 · Denominator 23

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Number of hospitalizations per 1000 long-stay resident days	1.1	2.1 1 pts better	1.9 0.8 pts better	Long Stay · 20240701-20250630 · Adjusted 1.1 · Observed 1.8 · Expected 3.1 · Used in QM five-star
Number of outpatient emergency department visits per 1000 long-stay resident days	1.7	2.3 0.6 pts better	1.8 0.1 pts better	Long Stay · 20240701-20250630 · Adjusted 1.7 · Observed 2.3 · Expected 2.3 · Used in QM five-star
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	41.3%	84.8% 43.5 pts worse	93.4% 52.1 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 40.0% · Q2 40.5% · Q4 43.6% · 4Q avg 41.3%
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine	50.0%	90.9% 40.9 pts worse	95.5% 45.5 pts worse	Long Stay · 2024Q3-2025Q2 · 4Q avg 50.0%
Percentage of long-stay residents experiencing one or more falls with major injury	5.6%	4.1% 1.5 pts worse	3.3% 2.3 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 6.7% · Q2 9.5% · Q4 0.0% · 4Q avg 5.6% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms	0.0%	14.7% 14.7 pts better	11.4% 11.4 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q4 0.0% · 4Q avg 0.0%
Percentage of long-stay residents who lose too much weight	0.0%	5.5% 5.5 pts better	5.4% 5.4 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q4 0.0% · 4Q avg 0.0%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	19.0%	25.3% 6.3 pts better	19.6% 0.6 pts better	Long Stay · 2024Q4-2025Q3 · Q1 20.9% · Q2 15.8% · Q4 20.0% · 4Q avg 19.0%
Percentage of long-stay residents who received an antipsychotic medication	8.7%	25.0% 16.3 pts better	16.7% 8 pts better	Long Stay · 2024Q4-2025Q3 · Q1 10.5% · Q2 9.1% · Q4 6.2% · 4Q avg 8.7% · Used in QM five-star
Percentage of long-stay residents who were physically restrained	0.0%	0.0% About the same	0.1% 0.1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q4 0.0% · 4Q avg 0.0%
Percentage of long-stay residents whose ability to walk independently worsened	13.3%	20.3% 7 pts better	16.3% 3 pts better	Long Stay · 2024Q4-2025Q3 · 4Q avg 13.3% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	17.2%	19.8% 2.6 pts better	14.9% 2.3 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 14.0% · Q2 23.7% · Q4 14.3% · 4Q avg 17.2% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder	1.7%	1.4% 0.3 pts worse	1.0% 0.7 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 2.5% · Q2 0.0% · Q4 3.1% · 4Q avg 1.7% · Used in QM five-star
Percentage of long-stay residents with a urinary tract infection	0.0%	2.6% 2.6 pts better	1.7% 1.7 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	8.4%	18.1% 9.7 pts better	19.8% 11.4 pts better	Long Stay · 2024Q4-2025Q3 · Q1 4.7% · Q2 13.7% · Q4 6.0% · 4Q avg 8.4%
Percentage of long-stay residents with pressure ulcers	1.8%	5.0% 3.2 pts better	5.1% 3.3 pts better	Long Stay · 2024Q4-2025Q3 · Q1 5.1% · Q2 0.0% · Q4 0.0% · 4Q avg 1.8% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	53.5%	66.4% 12.9 pts worse	81.7% 28.2 pts worse	Short Stay · 2024Q4-2025Q3 · Q1 52.3% · Q2 43.9% · Q3 51.4% · Q4 67.4% · 4Q avg 53.5%
Percentage of short-stay residents who had an outpatient emergency department visit	25.3%	13.4% 11.9 pts worse	12.0% 13.3 pts worse	Short Stay · 20240701-20250630 · Adjusted 25.3% · Observed 22.5% · Expected 9.9% · Used in QM five-star
Percentage of short-stay residents who newly received an antipsychotic medication	1.6%	2.2% 0.6 pts better	1.6% About the same	Short Stay · 2024Q4-2025Q3 · Q1 3.3% · Q2 2.9% · Q3 0.0% · Q4 0.0% · 4Q avg 1.6% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	2.4%	63.5% 61.1 pts worse	79.7% 77.3 pts worse	Short Stay · 2024Q3-2025Q2 · 4Q avg 2.4%
Percentage of short-stay residents who were rehospitalized after a nursing home admission	24.6%	25.3% 0.7 pts better	23.9% 0.7 pts worse	Short Stay · 20240701-20250630 · Adjusted 24.6% · Observed 19.7% · Expected 19.1% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2024-11-07 · Fire 2024-11-07

9 health deficiencies

Top issue: Pharmacy Service (3 deficiencies)

1 fire-safety deficiencies

Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)

Cycle 2 Health 2023-08-31 · Fire 2023-08-31

10 health deficiencies

Top issue: Resident Assessment and Care Planning (4 deficiencies)

1 fire-safety deficiencies

Top issue: Miscellaneous (1 deficiency)

Cycle 3 Health 2021-07-30 · Fire 2021-07-30

15 health deficiencies

Top issue: Resident Assessment and Care Planning (7 deficiencies)

4 fire-safety deficiencies

Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)

Fire safety

Fire-safety citations

F · Potential for more than minimal harm 2024-11-07

K920 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure proper usage of power strips and extension cords.

Corrected 2024-12-17

F · Potential for more than minimal harm 2023-08-31

K753 · Miscellaneous Deficiencies

Fire Safety

Have restrictions on the use of highly flammable decorations.

Corrected 2023-10-06

F · Potential for more than minimal harm 2021-07-30

K281 · Egress Deficiencies

Fire Safety

Install proper backup exit lighting.

Corrected 2021-09-10

F · Potential for more than minimal harm 2021-07-30

K741 · Miscellaneous Deficiencies

Fire Safety

Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.

Corrected 2021-09-10

F · Potential for more than minimal harm 2021-07-30

K920 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure proper usage of power strips and extension cords.

Corrected 2021-09-10

F · Potential for more than minimal harm 2021-07-30

K923 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have proper medical gas storage and administration areas.

Corrected 2021-09-10

Inspection history

Recent health citations

D · Potential for more than minimal harm 2024-11-07

F578 · Resident Rights Deficiencies

Health

Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.

Corrected 2024-12-17

D · Potential for more than minimal harm 2024-11-07

F584 · Resident Rights Deficiencies

Health

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

Corrected 2024-12-17

D · Potential for more than minimal harm 2024-11-07

F638 · Resident Assessment and Care Planning Deficiencies

Health

Assure that each resident’s assessment is updated at least once every 3 months.

Corrected 2024-12-17

D · Potential for more than minimal harm 2024-11-07

F677 · Quality of Life and Care Deficiencies

Health

Provide care and assistance to perform activities of daily living for any resident who is unable.

Corrected 2024-12-17

D · Potential for more than minimal harm 2024-11-07

F755 · Pharmacy Service Deficiencies

Health

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Corrected 2024-12-17

D · Potential for more than minimal harm 2024-11-07

F758 · Pharmacy Service Deficiencies

Health

Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.

Corrected 2024-12-17

D · Potential for more than minimal harm 2024-11-07

F759 · Pharmacy Service Deficiencies

Health

Ensure medication error rates are not 5 percent or greater.

Corrected 2024-12-17

D · Potential for more than minimal harm 2024-11-07

F812 · Nutrition and Dietary Deficiencies

Health

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Corrected 2024-12-17

D · Potential for more than minimal harm 2024-11-07

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2024-12-17

E · Potential for more than minimal harm 2023-08-31

F690 · Quality of Life and Care Deficiencies

Health

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

Corrected 2023-10-06

E · Potential for more than minimal harm 2023-08-31

F755 · Pharmacy Service Deficiencies

Health

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Corrected 2023-10-06

E · Potential for more than minimal harm 2023-08-31

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2023-10-06

D · Potential for more than minimal harm 2023-08-31

F637 · Resident Assessment and Care Planning Deficiencies

Health

Assess the resident when there is a significant change in condition

Corrected 2023-10-06

D · Potential for more than minimal harm 2023-08-31

F641 · Resident Assessment and Care Planning Deficiencies

Health

Ensure each resident receives an accurate assessment.

Corrected 2023-10-06

D · Potential for more than minimal harm 2023-08-31

F656 · Resident Assessment and Care Planning Deficiencies

Health

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Corrected 2023-10-06

D · Potential for more than minimal harm 2023-08-31

F661 · Resident Assessment and Care Planning Deficiencies

Health

Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.

Corrected 2023-10-06

D · Potential for more than minimal harm 2023-08-31

F698 · Quality of Life and Care Deficiencies

Health

Provide safe, appropriate dialysis care/services for a resident who requires such services.

Corrected 2023-10-06

D · Potential for more than minimal harm 2023-08-31

F730 · Nursing and Physician Services Deficiencies

Health

Observe each nurse aide's job performance and give regular training.

Corrected 2023-10-06

D · Potential for more than minimal harm 2023-08-31

F947 · Nursing and Physician Services Deficiencies

Health

Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.

Corrected 2023-10-06

E · Potential for more than minimal harm 2021-07-30

F641 · Resident Assessment and Care Planning Deficiencies

Health

Ensure each resident receives an accurate assessment.

Corrected 2021-09-10

E · Potential for more than minimal harm 2021-07-30

F812 · Nutrition and Dietary Deficiencies

Health

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Corrected 2021-09-10