MCQC Nursing Home Violations 2007

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Missouri Long-term Care Facility

Notices of Non-Compliance

2007

2007 Nursing Home Non-Compliance by Region:

1. Southwest Region
2. Southeast Region
3. Kansas City Region
4. Northwest Region
5. Northeast Region
6. Central Region
7. St. Louis Region

SOUTHEAST REGION
Facility: St. Francois Manor, Inc. Farmington, MO 118-Bed Skilled Nursing Facility Date of Notice: January 2007	Owner: St. Francois Place, LLC Operator: St. Francois Manor, Inc. Registered Agent: Sharo Shirshekan	Legal Action: Class I Notice of Noncompliance
Description: The facility failed to provide protective oversight and failed to provide sufficient numbers and sufficiently qualified nursing personnel to prevent one resident from eloping from the facility. The facility failed to ensure one resident (Resident #1) received adequate supervision by sufficient numbers of qualified staff to prevent elopement, failed to ensure staff knew the codes to all keypads in the locked units, failed to ensure all the keypads were functioning and failed to take measures to ensure residents did not know the codes to the keypads. The facility identified that Resident #1 had a history of elopement. Resident #1 resided on the locked 400 hall. The facility assigned one staff person to cover both the 400 and 500 halls on the night shift of 12/16/06. Twelve residents resided on the locked 400 hall and nine residents resided on the locked 500 hall. Resident #1 knew the code to the keypad to go outside into the courtyard. PT A did not know the code to go outside and return the resident to the facility. While PT A went to another part of the facility to find out what the keypad code was, Resident #1 climbed over the courtyard fence and hitchhiked to a family member's home in St. Louis. In addition, the keypad on the outside of the 400 hall did not function and neither residents nor staff would have been able to reenter the facility through that door.
Facility: Chaffee Nursing Center Chaffee, MO 71-Bed Skilled Nursing Facility Date of Notice: March 2007	Owner: Chaffee Nursing, LLC Operator: Same Registered Agent: Husch Registered Agent, Inc.	Legal Action: Class I Notice of Noncompliance
Description: The facility failed to: assure one resident was free of verbal, physical and mental abuse by a staff person; to thoroughly investigate the allegations of abuse; to prevent the potential for further abuse of this resident and other residents, as the facility allowed the staff person to care for residents from 1/22-3/2/07 after the administrator and Director of Nurses became aware of the allegations; to report the allegations of abuse to the state survey and certification agency that abuse had occurred.
Facility: Caruthersville Nursing Center Caruthersville, MO 94-Bed Skilled Nursing Facility Date of Notice: March 2007	Owner: Pemiscot County Memorial Hospital Operator: Same Registered Agent: Not Listed	Legal Action: Class I Notice of Noncompliance
Description: The facility failed to ensure staff used proper technique when repositioning residents in bed. This practice resulted in an injury, which required emergency medical treatment for one resident.
Facility: Country View Residential Care Gideon, MO 12-Bed Residential Care Facility Date of Notice: June 2007	Owner: Randolph, Carroll & Karen Operator: Carroll Randolph Registered Agent: Not Listed	Legal Action: Class I Notice of Noncompliance
Description: The facility failed to provide twenty-four (24) hour protective oversight for four residents (Resident #1, #2, #3, and #4), when the manager left the facility to take a resident to a doctor's appointment and left residents unattended in the facility and gave a resident (Resident #1) instruction to give the other residents left in the facility noon medications she had set up prior to leaving the facility. The facility also failed to ensure a safe method of medication control and use and failed to ensure that individuals are certified to administer medications. This effected (sic) Residents #1, #2, and #3 with the potential to affect all the residents. The facility also failed to document medications administered in the Medication Administration Record (MAR) for eight of eight (Resident #1, #2, #3, #4, #5, #6, #7, and #8) residents.
Facility: Clearview Nursing Center Sikeston, MO 98-Bed Skilled Nursing Facility Date of Notice: September 2007	Owner: SEMO Care Centers, Inc. Operator: N & R Sikeston at Clearview, Inc. Registered Agent: Charlotte Stutts	Legal Action: Uncorrected Class II Notice of Noncompliance
Description: On July 17, 2007, a survey was conducted at this facility. A revisit was conducted on September 13, 2007. During the revisit, the facility was found to have uncorrected deficiencies in the areas of Administration and Resident Care, Dietary Requirements, and Sanitation Requirements for Food Service.
Facility: Essex Residential Care Essex, MO 50-Bed Assisted Living Facility Date of Notice: December 2007	Owner: Theodore A. Elliott Operator: Same Registered Agent: Not Listed	Legal Action: Class I Notice of Noncompliance
Description: The facility failed to ensure there was a working fire alarm system and a fault with part of the fire alarm system was corrected immediately upon discovery. On 11/27/07 a resident activated the fire alarm by pulling the pull station in the dining room. On 11/29/07, the fire alarm panel showed the trouble light was illuminated but had been silenced. The fire alarm panel and the pull station were not reset until 11/29/07. When tested, the fire alarm panel showed “System Normal” and the alarm sounded when tested. The facility census was 48 residents.
Facility: Country Gardens Cape Girardeau, MO 56-Bed Assisted Living Facility Date of Notice: December 2007	Owner: Sample, Johnnie & Tomi Operator: Country Gardens, Inc. Registered Agent: Tomi Sample	Legal Action: Class II Notice of Noncompliance
Description: The facility staff failed to provide adequate oversight and supervision of one resident with a history of elopement and arson from leaving the facility without the guardian's approval. Resident #1 left the facility on two separate occasions; the first time the resident left he/she was gone an hour and the second resident was gone overnight. In addition, the facility failed to develop and implement interventions to monitor the resident after the facility had a fire, even though staff suspected the resident started the fire.