MCQC Nursing Home Violations 2007

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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

ST. LOUIS REGION
Facility: Tanglewood Care Center Pacific, MO 12-Bed Residential Care Facility Date of Notice: January 2007	Owner: Not Listed Operator: Not Listed Registered Agent: Not Listed	Legal Action: DENIAL OF LICENSURE
Description: The operator has failed to provide a complete application, including all required attachments, demonstrating financial capacity to operate the facility. The operator failed to provide additional information related to the application within (10) working days of the change or of SLTC's request.
Facility: Tanglewood Care Center Pacific, MO 12-Bed Residential Care Facility Date of Notice: February 2007	Owner: Not Listed Operator: Not Listed Registered Agent: Not Listed	Legal Action: RECISSION OF DENIAL AND RE-DENIAL OF APPLICATION FOR LICENSURE
Description: The operator has failed to provide a complete application, including all required attachments, demonstrating financial capacity to operate the facility. The operator failed to provide additional information related to the application within 10 working days of the change or of SLTC's request. The facility has had a history of chronic noncompliance with SLCR standards between September 2002 and present as identified in Statements of Deficiencies previously provided to the facility and the Statement of Deficiencies enclosed with this letter. (Letter on file with MCQC).
Facility: Lakewood Care Center Pacific, MO 12-Bed Residential Care Facility Date of Notice: January 2007	Owner: Converse, Richard & Audrey Operator: Not Listed Registered Agent: Not Listed	Legal Action: DENIAL OF LICENSURE
Description: The operator has failed to provide a complete application, including all required attachments, demonstrating financial capacity to operate the facility. The operator failed to provide additional information related to the application within (10) working days of the change or of SLTC's request.
Facility: Lakewood Care Center Pacific, MO 12-Bed Residential Care Facility Date of Notice: February 2007	Owner: Converse, Richard & Audrey Operator: Not Listed Registered Agent: Not Listed	Legal Action: RECISSION OF DENIAL AND RE-DENIAL OF APPLICATION FOR LICENSE
Description: The operator has failed to provide a complete application, including all required attachments, demonstrating financial capacity to operate the facility. The operator failed to provide additional information related to the application within 10 working days of the change or of SLTC's request. The facility and the operator are not in substantial compliance with the provisions of sections 198.003 to 198.096 and the standards established thereunder. The facility has had a history of chronic noncompliance with SLCR standards between September 2002 and present as identified in Statements of Deficiencies previously provided to the facility and the Statement of Deficiencies enclosed with this letter. (Letter on file with MCQC).
Facility: Converse Home Florissant, MO 12-Bed Residential Care Facility Date of Notice: January 2007	Owner: Converse, Richard & Audrey Operator: Not Listed Registered Agent: Not Listed	Legal Action: DENIAL OF LICENSURE
Description: The operator has failed to provide a complete application, including all required attachments, demonstrating financial capacity to operate the facility. The operator failed to provide additional information related to the application within (10) working days of the change or of SLTC's request.
Facility: Autumn View Gardens at Schuetz Road St. Louis, MO 100-Bed Assisted Living Facility Date of Notice: February 2007	Owner: Not Listed Operator: Bethesda Foundation Registered Agent: C T Corporation System	Legal Action: Class I Notice of Noncompliance
Description: The facility failed to maintain an adequate number of staff in the facility on the night shift for 16 out of 20 night shifts reviewed during the month of 1/07. Facility staff failed to have sufficient staff to monitor and provide care to meet the needs of 14 residents and meet the staffing requirements for fire safety. Also, the facility staff failed to meet the needs of three residents who voiced thoughts of suicide. One resident stated he/she was going to kill him/herself after the holidays. The facility did hospitalize the resident, but failed to monitor or develop an interventional plan to address the resident's earlier suicidal ideations. Staff found the resident dead in his/her room on 1/5/07, after staff had not seen the resident for approximately 13 hours. The facility staff failed to notify the physicians or monitor two other residents who voiced suicidal thoughts.
Facility: Alexian Brothers Lansdowne Village St. Louis, MO 80-Bed Skilled Nursing Facility Date of Notice: February 2007	Owner: Not Listed Operator: Alexian Brothers Lansdowne Village Registered Agent: C T Corporation	Legal Action: Class I Notice of Noncompliance
Description: The facility failed to provide the necessary care and services. Facility staff failed to ensure the resident's physician understood the resident's critical laboratory values, monitor the resident, follow physician orders and keep the physician informed of the resident's status. The resident was hospitalized on 12/26/06 and diagnoses (sic) with severe dehydration and a urinary tract infection. The resident expired on 2/07/07.
Facility: Carrie Elligson Gietner Home St. Louis, MO 120-Bed Skilled Nursing Facility Date of Notice: February 2007	Owner: GMG Properties LLC Operator: GMG, Inc. Registered Agent: Susan Makhamreh	Legal Action: Class I Notice of Noncompliance
Description: The facility failed to provide the necessary care and services to two residents. Facility staff failed to provide cardiopulmonary resuscitation to two residents who were unresponsive and had orders to resuscitate. One resident was in the dining room with staff, who observed the resident become unresponsive. The other resident was found unresponsive in his/her room and CPR was not initiated. In addition, 911 was not called for either resident.
Facility: Normandy Nursing Center St. Louis, MO 116-Bed Skilled Nursing Facility Date of Notice: February 2007	Owner: Creative Health Care Services St. Louis Operator: Normandy Associates, Inc. Registered Agent: Kerry Kauffmann	Legal Action: Class I Notice of Noncompliance
Description: The facility failed to provide adequate oversight and supervision. Facility staff failed to develop and implement interventions to address one resident's history of alcohol abuse. On several occasions the resident was found on the street intoxicated and transferred to the emergency room. On at least one of these occasions the resident sustained an injury, which required sutures.
Facility: Converse Home Florissant, MO 12-Bed Residential Care Facility Date of Notice: April 2007	Owner: Converse, Richard & Audrey Operator: Converse Residential Adult Home Registered Agent: Husch Registered Agent, Inc.	Legal Action; Class I Notice of Noncompliance
Description: Based on observation and interview, the facility failed to ensure the manager intervened on behalf of the residents when an employee was verbally and mentally abusive to nine residents. Based on observation and interview, the facility failed to ensure the manager responded when an employee's actions adversely affected the residents for nine of nine sampled residents.
Facility: Brentmoor Retirement Community St. Louis, MO 36-Bed Residential Care Facility Date of Notice: June 2007	Owner: Brentmoor Retirement Community LLC Operator: Brentmoor Delmar-SPVEF, LLC Registered Agent: Lisa Pool Byrne, Esq.	Legal Action: Uncorrected Class II Notice of Noncompliance
Description: A licensure inspection was completed on 3/27/07. The facility was not in substantial compliance with participation requirements. A revisit was completed on 6/13/07. The facility staff failed to ensure one resident was physically capable of negotiating a normal path to safety in the event of a fire or other emergency.
Facility: Abbey Care Center St. Louis, MO 126-Bed Skilled Nursing Facility Date of Notice: August 2007	Owner: J & J Assoc., LLC Operator: Fairfield Nursing and Rehab, Inc. Registered Agent: Charlotte Stutts	Legal Action: Uncorrected Class II Notice of Noncompliance
Description: A survey was completed on 6/21/07. The facility was not in substantial compliance with participation requirements. A revisit was completed on 8/09/07. The facility staff failed to: Maintain a clean, comfortable and homelike environment in eight of ten sampled resident rooms, three resident accessible corridors and one beauty parlor. Provide adequate pain control to one resident who experienced immense pain, according to facility staff in his/her left hip. Provide appropriate catheter care for two sampled residents with indwelling urinary catheters. Provide adequate care to minimize the risk of accidents and/or injuries when using a mechanical lift for two resident transfers. Ensure floors were clean and free of sticky wax build-up. Provide pest control of gnats, flies and ants in the facility.
Facility: Whispering Oaks Health Care Center Wildwood, MO 70-Bed Residential Care Facility Date of Notice: August 2007	Owner: Not Listed Operator: Whispering Oaks Health Care Center, Inc. Registered Agent: Eric F. Fink, Jr.	Legal Action: Uncorrected Class II Notice of Noncompliance
Description: A licensure inspection was completed on 4/27/07. The facility was not in compliance with participation requirements. A revisit was completed on 7/24/07. The facility staff failed to follow physician orders and administer inhalers to three residents as ordered by the residents' physician and failed to assess one resident's blood pressure prior to administering medication. The facility staff failed to obtain physician orders for four residents to administer their own medications and/or store medications in their rooms. Facility staff failed to make repairs to ceiling tiles, which were stained, bowed and/or had holes, replace scuffed and marred doors exposing the wood underneath. Also, the facility failed to ensure resident trust fund accounts were accurate by reconciling the resident trust fund bank account for the months of May and June 2007.
Facility: Oak Park Nursing Center St. Louis, MO 120-Bed Skilled Nursing Facility Date of Notice: September 2007	Owner: Oak Park Real Estate, LLC Operator: Berthold Nursing Center, Inc. Registered Agent: Clifton L. Shirrell	Legal Action: Class I Notice of Noncompliance
Description: The facility failed to provide a self-closing device into which staff could empty ashes and cigarette butts. The facility failed to fully assess the need for physical restraints, and to ensure that residents wore the least restrictive restraint possible. The facility failed to provide clean walls, floors, and equipment for residents. The facility failed to provide housekeeping and maintenance services necessary to provide a clean, orderly interior. The facility failed to provide appropriate and timely wound care for one resident. The facility failed to provide appropriate catheter care. The facility failed to serve a therapeutic diet as ordered for the residents. The facility failed to follow approved puree and enhanced cereal recipes when preparing food for residents and failed to serve dietitian approved substitute menu items for residents. The facility failed to serve cold foods at 45 degrees Fahrenheit or colder and failed to hold potentially hazardous foods at 140 degrees (F) or above.
Facility: Parkview Residential Care Crystal City, MO 52-Bed Residential Care Facility Date of Notice: September 2007	Owner: Jean-Baptist, Philippe & Debra Hahn Operator: DMP Enterprises, Inc. Registered Agent: Mark C. Goldenberg	Legal Action: Class II Notice of Noncompliance
Description: On 9/05/07 a complaint investigation was completed. The facility staff failed to assess and meet the needs of one resident who had a decline in mental status and exhibited inappropriate behaviors. The operations manager stated the resident's mental status had deteriorated and the facility could not meet the resident's needs. Interviews with emergency room physicians indicated the resident required a higher level of care. In addition, the facility failed to provide adequate oversight and supervision of the resident when the resident left the facility without staff knowledge on several occasions. On 8/11/07, the police picked up the resident for attempting to gain entry into a business located 2.6 miles from the facility and was transported to the hospital emergency room. The resident was wearing a long sleeve shirt and winter coat when he/she left the facility, even though the temperature that day was 100 degrees Fahrenheit. The resident's temperature was 106.2 degrees Fahrenheit and was admitted to the hospital with a diagnosis of hyperthermia (heatstroke).
Facility: Delmar Gardens of Meramec Valley Fenton, MO 190-Bed Skilled Nursing Facility Date of Notice: September 2007	Owner: Not Listed Operator: Delmar Gardens of Meramec Valley, LLC Registered Agent: Husch Registered Agent, Inc.	Legal Action: Class I Notice of Noncompliance
Description: A complaint investigation was completed on 9/10/07. The facility staff failed to properly assess the use of side rails and develop appropriate interventions to protect one resident from injury. Review of the resident's medical record showed incomplete restraint assessments, no physician's order for side rail use and the use of a personal alarm in the wheelchair and bed as an audible alert for nursing staff. On 8/03/07 facility staff transferred the resident from the wheelchair to bed and did not apply the personal alarm in bed. At 10:20 p.m., facility staff found Resident #1 with his/her neck against a side rail and his/her body hanging down to the floor, resulting in the resident's death. Investigation by the medical examiner revealed the resident's cause of death was due to accidental positional asphyxiation.
Facility: Rosewood Care Center St. Louis County, Inc. St. Louis, MO 120-Bed Skilled Nursing Facility Date of Notice: December 2007	Owner: Not Listed Operator: Rosewood Care Center of St. Louis County, Inc. Registered Agent: Steven M. Hamburg	Legal Action: Uncorrected Class II Notice of Noncompliance
Description: The facility failed to administer an anti-infective medication as ordered by the physician, and notify the physician of the resident's change in condition for one resident.
Facility: Page Manor St. Louis, MO 49-Bed Assisted Living Facility Date of Notice: December 2007	Owner: Malik, Saleh M. Operator: Malik Home, LLC Registered Agent: Saleh Malik	Legal Action: Uncorrected Class II Notice of Noncompliance
Description: A licensure inspection was completed on 9/13/2007, the facility was not in compliance with participation requirements. A revisit was completed on 11/21/2007. The facility failed to conduct premove-in screening prior to admission for one resident with a history of suicide attempts. Facility staff admitted the resident on 9/11/2007 but failed to complete the screening until 9/12/2007.
Facility: St. Elizabeth Healthcare & Rehabilitation Center Florissant, MO 150-Bed Skilled Nursing Facility Date of Notice: December 2007	Owner: Not Listed Operator: St. Elizabeth Healthcare & Rehabilitation Center, LLC Registered Agent: Mark S. Rubin	Legal Action: Uncorrected Class II Notice of Noncompliance
Description: The facility failed to follow their behavioral emergency policy to ensure one resident (Resident #39) was free from physical, mental abuse, involuntary seclusion and discipline, when staff removed the resident from his/her room against the resident's will and physically forced the resident to go to the secure unit. Staff grasped the resident by the upper arms and forced the resident approximately 25-30 feet through the hallway to the nurses' station on 11/12/07. The resident sustained bruising under his/her upper arms. The facility also failed to immediately notify the Administrator, report to the proper authorities and thoroughly investigate when the resident sustained bruising under his/her upper arms from being physically forced by staff through the hallway.
Facility: Affton House Affton, MO 19-Bed Residential Care Facility Date of Notice: December 2007	Owner: Not Listed Operator: Laura Roques Registered Agent: Not Listed	Legal Action: Class II Notice of Noncompliance
Description: A licensure inspection was completed on 11/27/07. The facility was not in substantial compliance with participation requirements. A revisit and complaint investigation was completed on 12/11/07. The facility failed to have the electrical wiring inspected since reopening in July 2007. The facility did not obtain a license with Department of Mental Health as required when caring for residents with mental illness and/or Mental Retardation as required in statute. In addition the facility staff failed to provide adequate supervision and oversight for one resident who left the facility for a hospital day program and upon his/her return to the facility told staff that he/she had ingested 499 aspirins. While at the day program, the resident talked about purchasing a lot of aspirin. The day program staff called the facility to report what the resident talked about and informed the facility to monitor the resident upon his/her arrival to the facility. The facility did not know the residents whereabouts from the time he/she got off the transportation van until the time he/she reentered the facility. The resident purchased five bottles of aspirin at a gas station/store located close to the facility. The resident expired on 10/18/07 after hospitalization for ingesting the 499 aspirin. Review of the facility history and cited violations and the circumstances the Section for Long Term Care Regulations has determined to deny the facility's application for a license to operate.