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Notices of Non-Compliance

2003

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

CENTRAL REGION

Date of Notice: March 2003

Registered Agent: C T Corporation System

Description: The facility staff physically and chemically restrained residents in response to out of control behavior. Also the facility did not provide training to staff how to deal with behaviors nor provide services to address resident’s mental and psychosocial adjustment difficulties.

Date of Notice: March 2003

Registered Agent: John H. Simmons

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Description: Resident #1 was admitted to the facility with a known history of inappropriate sexual behavior. Facility staff was directed to keep Resident #1 separated from confused female residents. Resident #1 had several incidents of leading confused female residents into unoccupied rooms. On 2/20/03, the night shift CAN left the special care unit door propped open and unsupervised. Resident #1 entered Resident #2’s room on the SCU, undressed himself and Resident #2 and was then found by two staff lying on top of Resident #2. Staff observed that Resident #1 had sexually penetrated Resident #2.

Date of Notice: April 2003

Registered Agent: Prentice-Hall Corp. System, Inc.

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Description: Resident #5 was admitted to the facility with wandering behaviors and staff was directed to complete 30 minute checks of the resident’s whereabouts. On 2/28/03, Resident #5 entered Resident #6’s room and pushed Resident #6 to the floor and Resident #6 sustained a hip fracture. On 3/7/03, Resident #5 entered Resident #7’s room and hit Resident #7 in the face, chest and twisted the resident’s arm leaving bruises. Also, the facility staff did not follow infection control practices when handling soiled linens by placing the soiled linens on the floor of the resident’s rooms.

Date of Notice: April 2003

Registered Agent: None

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Description: On 2/28/03 Resident #9’s physician ordered a urinalysis and culture and sensitivity. Facility staff did not obtain the urine for the urinalysis until five days after receiving the physician order. The physician also ordered a repeat UA done in 14 days (3/22/02); however the UA was not completed until SLCR staff brought the physician order to facility staff’s attention on 3/24/03. Resident #9’s physician also ordered Darvocet to relieve pain. Observation on 3/24/03 at 2:30 showed Resident #9 requested pain medication after receiving incontinence care from two certified nurse aides. Neither CAN reported Resident’ #9’s request for pain medication to the charge nurse.

Date of Notice: April 2003

Registered Agent: John C. Finley

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Description: The facility failed to provide adequate supervision, evaluate the cause of repeated falls, and plan interventions to prevent avoidable accidents and possible injuries for one resident. Dietary staff failed to follow recipes to assure ten residents on pureed diets received appropriate portion sizes.

Date of Notice: April 2003

Registered Agent: None

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Description: Facility staff failed to check one resident’s protime (blood clotting time test) level as ordered by the physician. On 3/25/03 Resident #1 had multiple bruising of unknown origin and staff checked the resident’s protime which was too high to calibrate. Despite this, staff continued to administer the resident’s coumadin (anticoagulant, blood thinner) therapy. On 3/26/03 the resident was transferred to the hospital with vaginal and rectal bleeding. The resident required two units of frozen plasma and two units of blood.

Date of Notice: May 2003

Registered Agent: None

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Description: The facility failed to provide one resident with adequate supervision to prevent his/her elopement from the facility. Resident #1 was last observed by facility staff on 5/4/03 sometime after 2:00 p.m. At 6:30 p.m. staff identified Resident #1 was missing from the facility. Two staff went to look for Resident #1, but were unable to locate the resident and returned to the facility. The facility did not contact anyone to assist in searching for Resident #1, despite the tornado watch and storm warnings at that time. At 6:14 p.m. police officers responded to a report of a person in a ditch. When the police arrived Resident #1 did not know his/her name or where he/she lived, breathing was “erratic” and the resident was transported to the hospital. Hospital staff contacted the facility at 6:30 p.m. to inform staff of Resident #1’s location.

Date of Notice: June 2003

Registered Agent: Sharo Shirshekan

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Description: Facility failed to ensure services met professional standards of quality. Facility staff administered eye drops in the wrong eye for one resident, failed to transcribe and administer a new medication order and failed to apply TED (support) hose for one resident. Facility also failed to prepare and serve the correct ingredients of pureed fish for residents who were on pureed diets.

Date of Notice: August 2003

Registered Agent: Don Chapman, Jr.

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Description: The 06/24/03 survey was the initial certification of the six beds at the facility. Facility had a nonconforming building sharing a common wall with less than a minimum two hour fire resistance rated separation wall. Facility plan of correction was to request an exception, which was not granted.

Date of Notice: September 2003

Registered Agent: James E. Guthrie

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Description: Facility staff assessed and identified Resident #1 as an elopement risk due to past attempts to follow her spouse from the building. On 8/24/03 Resident #1 made two attempts to leave the building/premises prior to her elopement. Facility staff did not implement their elopement policy and procedure when the resident attempted to leave the building prior to the actual elopement. Resident was last observed in the facility at 3:00 p.m. At 4:30 p.m. an unidentified woman returned the resident to the facility. The woman found the resident at the overpass at Highways 00 and M, a busy four-lane highway which is three tenths of a mile from the facility.

Date of Notice: October 2003

Registered Agent: Charlotte Stutts

Class I Notice of Noncompliance

Description: Facility failed to provide protective oversight and supervision for one resident who eloped from the facility on 10/4/03. A community member found the resident at the car wash near the intersection of Business 54 and Highway Z and notified the facility.

Date of Notice: October 2003

Registered Agent: Kem Schwieder

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Description: Facility staff failed to develop interventions and update the plan of care for two residents to reflect the residents’ current needs. Facility failed to provide adequate supervision and assistance devices to prevent accidents for one resident with recurrent falls. Facility staff failed to store medications in locked compartments. Facility staff left the medication room door open and unattended by facility staff.

Date of Notice: October 2003

Registered Agent: Donnie R. Jennings

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Description: Facility staff failed to document monthly pressure checks were completed for one of six fire extinguishers in an area where combustibles were stored. Facility staff failed to ensure the range hood extinguishing system was inspected and certified annually. Facility staff failed to maintain four of six exit signs so they were illuminated by emergency lighting. Also the facility failed to maintain three of six emergency lights were of sufficient intensity for exits, stairs and resident corridors. Facility failed to maintain building in good repair. Facility staff failed to ensure extension cords used had no more than one appliance connected and were not placed through a doorway. Facility staff failed to follow menus as planned. Facility failed to minimize the presence of flies in the facility. Facility failed to ensure two of two double sinks were clean and in good repair. Facility staff failed to ensure foods that have been cooked and then refrigerated were reheated rapidly to the appropriate temperature before being served. Facility staff failed to ensure non-food contact surfaces of equipment were clean and free of accumulation of dust, dirt and grease. Facility staff failed to ensure moist cloths used for wiping up food spills on kitchenware and food contact surfaces were properly rinsed and stored in sanitizing solution. Also, facility staff failed to maintain an adequate bond for operators to hold resident funds.

Date of Notice: October 2003

Registered Agent: Sharo Shirshekan

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Description: Facility staff failed to follow physician orders for two residents. Facility staff failed to follow the recipe as directed for residents on a regular diet and six residents who required a pureed diet. Facility staff failed to offer residents a snack at bedtime. Facility staff failed to wash or sanitize their hands during a meal. Also, facility staff failed to properly store the scoop to the ice chest.

Date of Notice: November 2003

Registered Agent: Charlotte Stutts

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Description: During the abbreviated survey of 9/11/03, the facility was cited for failure to follow physician orders. During the revisit on 11/6/03, the facility remained out of compliance. Facility staff failed to monitor and record three residents’ blood sugar levels as ordered by their physician. Also, the facility staff did not administer medications as ordered by the physician for one resident.

Date of Notice: December 2003

Registered Agent: C T Corporation System

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Description: Facility failed to provide adequate supervision and assistance devices to prevent accidents. Facility staff failed to develop and implement interventions even though Resident #1 had made several comments and attempts to leave the facility. On 11/28/03, Resident #1 left the facility without staff knowledge and was picked up by an anonymous restaurant employee along Hwy. 50 and taken to a local restaurant located 8 miles from the facility. Resident sustained abrasions to the face and hands.

KANSAS CITY REGION

Date of Notice: January 2003

None

Uncorrected Class II Notice of Non-Compliance

Administration and Resident Care Requirements: Facility failed to ensure one resident was mentally capable of negotiating a normal path to safety; ensure staff followed physician orders for two residents. Sanitation Requirement for Food Services: The facility failed to maintain the internal temperature of potentially hazardous foods at 140 F degrees or above during meal service; maintain all kitchen food-contact surfaces in a clean condition.

Date of Notice: January 2003

Gary Marvine

Uncorrected Class II Notice of Non-Compliance

Administration and Resident Care Requirements: facility failed to develop a system to ensure the RN consultant is notified of residents exhibiting behaviors or symptoms that need an evaluation by an RN. (Uncorrected Class II violation); facility failed to utilize the RN consultant in the development, review and/or revision of policies and procedures regarding the investigation and final disposition of all investigations of abuse. (Uncorrected Class III violation). General Sanitation: facility failed to develop and implement facility maintenance and repair schedule. (Uncorrected Class III violation); facility failed to maintain the flooring of the first floor bathroom in good repair. (Uncorrected Class III violation). Fire Safety Standards: facility failed to keep corridors designated as a fire exit free of obstruction (New Class II violation); facility failed to develop and implement policies and procedures that ensured staff supervised residents while the residents smoked and ensured residents only smoked in designated areas within the facility. (New Class II violation). Physical Plant Requirements: facility failed to have a specifically designated area as a clean utility room on the first floor (New Class III violation)

Date of Notice: January 2003

Registered Agent: CT Corporation Syst.

Uncorrected Class II Notice of Non-Compliance

Description: A complaint investigation was completed on 11/8/02. A revisit was conducted in conjunction with the annual licensure inspection on 1/10/03. The facility had an uncorrected Class II violation in the area of Administration and Resident Care requirements. The facility also had new Class II and new Class III violations in the areas of Physical Plant requirements, Resident Rights, and Fire Safety Standards. A registered nurse failed to follow the facility’s policy and procedure and did not check placement of a gastrostomy tube prior to administration of water and medications to one resident. Facility staff failed to notify the physician of the registered dietitian’s recommendations to address one resident’s weight loss.

Date of Notice: January 2003

Registered Agent: Gordon Goodman

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General Sanitation Requirements: facility failed to eliminate the odor of sewage from inside and outside the facility that originated from the facility’s septic tank; ensure floors, walls and ceilings were clean and in good repair; and failed to have a functional septic sewage system. Sanitation Requirements for Food Service: facility failed to ensure all staff wore hair restraints when preparing and serving food to residents; ensure hazardous food is maintained at appropriate temperatures during meal service, that hot food was served hot; ensure that food is prepared and stored in a sanitary manner; store utensils to prevent contamination or keep non-food contact surfaces clean; ensure resident-use dishes and utensils are cleaned and sanitized properly. Resident Rights: facility failed to provide full and adequate notice before discharging residents; and failed to ensure residents are not required to perform services for the facility.

Date of Notice: March 2003

Registered Agent: The Corporation Company

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Description: Facility staff failed to provide protective oversight and failed to provide personal attention and nursing care in accordance with Resident #1’s condition and consistent with current acceptable nursing practice. The physician wrote an order that Resident #1 was a Full Code. On 2/24/03, Resident #1 developed lung congestion with a decreased oxygen saturation level, had labored and uneven respirations and complained of chest pain. LPN A, the only licensed nurse in the facility, did not notify the physician. Instead, LPN A went to the RCF portion of the facility to obtain some medication for another resident. Fifteen minutes later, a CAN went to find LPN A and reported Resident #1 had no pulse or respirations. LPN A did not begin CPR or call 911. LPN A notified the physician who gave an order to pronounce the resident as deceased.

Date of Notice: March 2003

Registered Agent: Joseph C. Tutera

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Description: On 2/25/03, SLCR completed a revisit and complaint investigation. A determination was made at that time, that conditions in the facility constituted an immediate jeopardy to the health, safety and welfare of residents. The facility did not provide adequate supervision and assistance devices to prevent accidents to one resident. Resident #1 was confused and had a history of elopements at other facilities when admitted to Highland Nursing and Rehab on 2/7/03. The facility identified Resident #1 at risk of elopement. However, on 2/8/03, Resident #1 left the facility and was gone for at least 30 minutes before the facility was alerted by police the resident was seen falling and striking his/her head on the pavement of a busy five-lane thoroughfare. Resident #1 was taken to a local hospital where the physician determined Resident #1 had bleeding in his/her head due to the closed head injury.

Date of Notice: March 2003

Registered Agent: Lawrence Thompson

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Fire Safety: facility failed: to complete yearly fire extinguisher maintenance of 10 or 10 fire extinguishers; to ensure hazardous areas are separated by at least one-hour construction; to maintain a smoke separation barrier between floors and to regulate the storage of unnecessary combustible materials; to provide flame-resistant window coverings. Physical Plant: facility failed: to maintain all resident and non-resident use areas clean, in good repair and free of significant damage; to ensure the elevator is maintained according to state and local codes. Administrative, Personnel and Resident Care: facility failed: to complete criminal background checks as required; to maintain complete personnel files of all employees; to provide protective oversight for one resident who leaves the facility without signing out; to follow physician orders for medications and laboratory tests; to obtain physician orders for one resident to self-control and self-administer medication; to ensure the administrator complied with all applicable laws and regulations for completing criminal background checks and that the facility’s elevator and boiler are in compliance with local and state codes and regulations. General Sanitation: facility failed: to maintain flooring clean and in good repair; to maintain plumbing free from leaks; to prevent entry of rodents and birds inside the facility by protecting openings to the outside; to maintain toilet fixtures clean and in good repair. Food Service Sanitation: facility failed: to ensure staff did not contaminate food during meal preparation by hand washing and/or changing gloves. To protect food from contamination during storage; to thaw chicken in a manner to prevent contamination; to maintain nonfood contact surfaces in an easily cleanable condition. Resident Rights: facility failed to post notices of noncompliance; to ensure residents have access to telephones and that residents could make and receive private telephone calls.

Date of Notice: March 2003

Registered Agent: Sharo Shirshekan

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Description: The facility failed to follow physician orders and provide treatment to a resident admitted to the facility with 2^nd degree burns. Also, the facility did not implement interventions to prevent the development of pressure sores for one resident and require staff to wash their hands after each direct resident contact as indicated by acceptable professional practice.

Date of Notice: May 2003

Registered Agent: T. H. Bennett

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Description: The facility staff failed to maintain hot water temperatures at a safe level. The temperatures were as high as 138 degrees F in resident rooms. Residents diagnosed with dementia and Alzheimer’s disease had access to the excessively hot water. The facility staff did not monitor water temperatures at the sinks in resident rooms and were unaware of the elevated temperatures.

Date of Notice: May 2003

Registered Agent: Gordon Goodman

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Fire Safety Standards: The facility failed to maintain the southeast smoke door so that it independently closed when released to self-closing action. Physical Plant Requirements: The facility failed to ensure resident rooms were heated to at least 68 degrees and failed to ensure functional nightlights were provided in all corridors/toilet areas. Administrative Personnel and Resident Care Requirements: The facility failed to provide protective oversight as residents had access to the area where the septic sewage system is located. The facility also failed to follow physician’s orders and failed to develop and implement a safe and effective system of medication control, as staff did not administer medication to residents as ordered, did not administer insulin according to physician orders and failed to obtain physician ordered medication from the pharmacy. Dietary Requirements: The facility failed to post menus and failed to enter into a written agreement for dietary consultation with a qualified person. General Sanitation Requirements: The facility failed to have a functional septic sewage system. Sanitation Requirements for Food Service: The facility failed to ensure that food is prepared and stored in a sanitary manner; failed to keep non-food contact surfaces clean; failed to ensure resident use dishes and utensils are manually washed, rinsed and sanitized in the correct manner; and failed to ensure the kitchen mechanical dishwasher sanitized resident use dishes and utensils properly.

Date of Notice: May 2003

Registered Agent: Sharo Shirshekan

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Description: Facility staff failed to ensure a resident was free from physical, verbal and mental abuse and implement protective measures during the investigation. On 4/22/02 Resident #1’s guardian and daughter-in-law observed the resident smoking outside the facility. The family members grabbed, yelled at and cursed the resident and would not allow the resident to leave the room. After approximately 10 minutes a facility staff entered the resident room and observed the daughter-in-law hitting the resident on the back. The facility did not implement interventions to protect the resident from family members until DHSS intervened.

Date of Notice: May 2003

Registered Agent: The Corporation Co.

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Description: The facility failed to provide two residents with adequate supervision to prevent their elopement from the facility. Resident #1 left the facility on 4/11/03 through an unsecured sliding glass door on the dementia unit, was picked up by a young couple passing by and taken to their home. A family member later returned the resident to the facility. On 4/14/03 Resident #1 left the facility without staff knowledge. Resident #2 attended the Easter egg hunt and was later found going down the street against traffic in a wheelchair.

Date of Notice: June 2003

Registered Agent: Gary L. Marvine

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Description: Facility staff gave one resident hot coffee which spilled on the resident’s lap causing 2^nd and 3^rd degree burns. The temperature log showed coffee temperatures ranged between 160 and 174 degrees F. The resident was on fluid restrictions and limited to four cups of fluid daily. Facility did not inform the physician of the extent of the burns. Facility staff did not document the treatment as prescribed by the physician. Two days after the burn the facility sent the resident to the hospital.

Date of Notice: June 2003

Registered Agent: The Corporation Co.

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Description: Facility failed to provide appropriate supervision and protective oversight for one resident who was identified as an elopement risk and placed on 15 minute checks. On 5/9/03 Resident #1 repeatedly paced the hallway stating he wanted to go home. The resident exited the facility sometime after 7:45 p.m. and was picked up by a passerby and taken to the fire station. The fire station notified the resident’s family member that Resident #1 was at the fire station. The facility was unaware the resident had eloped. The police returned the resident to the facility at 8:28 p.m.

Date of Notice: August 2003

Registered Agent: SHB Registered Agent, Inc.

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Description: Facility failed to assure each resident receives adequate supervision and assistance to prevent accidents. At the resident’s request, facility staff wheeled the resident outside into the courtyard. Staff left the resident unattended in 91/4 degree heat for approximately three hours. Resident was hospitalized and treated.

Date of Notice: August 2003

Registered Agent: Lawrence Thompson

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Description: Facility failed to provide fire extinguishers so there is no more than 100 feet travel distance to the extinguisher and failed to conduct monthly inspections of fire extinguishers. Facility failed to provide adequate fire separation of hazardous areas (boiler room) and failed to ensure the boiler was in compliance with local and state codes. Facility failed to provide complete personnel files for two employees and failed to provide adequate protective oversight for one resident. Resident room floors and areas of the kitchen were not maintained clean and in good repair. Facility failed to protect openings to the outside to prevent the entry of flies and insects into the building.

Date of Notice: October 2003

Registered Agent: Joseph Tutera

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Description: A complaint investigation was completed on 8/5/03. A revisit was completed on 10/3/03. Facility is not in substantial compliance in the area of Administration and Resident Care due to an uncorrected violation. Facility did not follow up on dietary recommendations to address weight loss and to notify the physician of that weight loss for one resident who received nutrition through a feeding tube.

Date of Notice: October 2003

Registered Agent: Gordon D. Goodman

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Description: The annual inspection was completed on 10/7/02. Revisits were completed on 1/9 and 4/1/03. A third revisit was completed on 9/23/03 and the facility remained in substantial noncompliance. Facility census was 29 residents. Violations are as follows: Facility failed to ensure one self-closing smoke door completely closed (uncorrected Class II, Fire Safety Requirements); Facility staff failed to obtain physician orders before administering insulin injections to one resident and failed to follow physician orders by not providing a special diet to one diabetic resident (uncorrected Class II, Administration, Personnel and Resident Care Requirements); Facility staff failed to post the menus for a modified diet in the kitchen (uncorrected Class III, Dietary Requirements); Facility failed to ensure hot water temperatures were 120 degrees F or below in resident use bath and shower rooms (new Class II, Physical Plant Requirements); Facility failed to ensure kitchen faucet was equipped with a backflow device after attaching a hose to the faucet. The hose is used to rinse resident use dishes and utensils (new Class III, Food Service Sanitation).

Date of Notice: November 2003

Registered Agent: George E. Kapke

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Description: During a licensure inspection and complaint investigation completed on 11/3/03, facility staff and administrator failed to provide protective oversight for 24 of 24 residents. Administrator failed to ensure boiler functioned properly, failed to lower facility temperatures, failed to evacuate residents to cooler areas, failed to ensure that facility staff reset the fire alarm when it sounded, failed to ensure that staff monitored residents during high-heat conditions, failed to provide residents with adequate hydration and failed to provide adequate interim cooling measures when the temperature exceeded 85 degrees. One resident residing on the second floor was found dead in a metal bed positioned next to the radiator. Autopsy revealed resident’s death was due to heat exposure.

Date of Notice: December 2003

Registered Agent: John R. Cook

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Description: On 9/26/03, complaint investigation completed. On 12/12/03, the revisit was completed and the facility was not in substantial compliance due to an uncorrected deficiency in the area of Administration and Resident Care. Facility staff failed to assess, prevent, identify and/or treat four out of 16 residents with pressure ulcers.

NORTHEAST REGION

Date of Notice: January 2003

Registered Agent: Joseph A. Shepard

Class I Notice of Non-Compliance

Description: The facility admitted and continued to care for two residents out of 12 residents who resided on the third floor locked behavioral unit. The residents displayed aggressive behaviors. Facility staff relied on manual restraint (as many as 10 people) and chemical restraints to “take the resident down.” One resident was taken down five times and injected with sedating drugs four times within eight hours. The Department of Mental Health group therapy was called after the resident received multiple injections and multiple “takedowns.” The therapy group was unable to evaluate due to the resident’s drugged condition. The facility did not request the residents be reevaluated after restraint use.

Date of Notice: January 2003

None

Uncorrected Class II Notice of Non-Compliance

Description: On 12/13/02, Resident #7 fell out of a low bed and sustained a laceration above his/her left eye, a contusion with a hematoma of the left orbit, and a contusion of the left elbow. The facility was aware the physician was unavailable at night and on weekends, however staff left a message on the physician’s home answering machine on 12/13/02 (Friday) at 9:05 p.m. Staff did not attempt to notify the nurse practitioner affiliated with the physician who was available on 12/13/02. The facility also failed to update the care plan and implement new interventions after the resident’s fall on 12/13/02.

Date of Notice: March 2003

Registered Agent: Martha E. Moore

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Description: Resident #1 was admitted to the facility on 2/12/03. After the resident’s family told staff the resident wandered and may attempt to leave the facility, staff applied a code alert bracelet. On 2/13/03 at 6:20 p.m., staff noted the resident eloped from the facility. Staff located the resident inside the fence of a municipal pool and transported the resident back to the facility. Facility staff believed the resident exited the facility through the front door after someone did not close the door properly. On 2/14/03 and 2/16/03, staff documented the resident continued to verbalize a desire to “go home.” Facility did not implement any new interventions to address the resident’s elopement risk. During the evening shift on 2/17/03, the resident said he/she was “going home.” At 9:30 p.m. the police called the facility to inform staff the resident was at a private residence. Facility was unaware the resident had left the facility. On 2/20/03 the resident exited from an unalarmed door and staff found the resident in the parking lot.

Date of Notice: May 2003

Registered Agent: Gary W. Shinn

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Description: Observation on 5/14/03 at 11:15 a.m. showed a warning/fault light on the main panel of the fire alarm system. Facility staff was unaware of when the problem with the fire alarm system began and failed to conduct a monthly test of the fire alarm system. An interview with the CMA manager revealed the fire alarm had sounded approximately the third week of April for no reason and the CMA had not been instructed on how to reset the fire alarm systems.

Date of Notice: June 2003

Registered Agent: Hal F. Juckette

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Description: Facility staff failed to assess Resident #1 after the resident experienced a decline in physical functioning and after readmission from the hospital on 5/15/03. Facility staff also failed to implement interventions to address the resident’s fall risk. On 5/1/03, a staff member attempted to take the resident to the dining room so he/she pushed the resident’s wheelchair. The resident fell out of the wheelchair and sustained cervical fractures which led to the resident’s death.

Date of Notice: June 2003

Registered Agent: CT Corporation Syst.

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Description: Facility failed to adequately assess a resident with a history of deep vein thrombosis (DVT) and failed to notify the resident’s physician regarding the resident’s condition until more than 24 hours after the onset of DVT symptoms. Resident was admitted to the hospital and underwent an above the knee amputation of the right leg.

Date of Notice: July 2003

Registered Agent: Charlotte Stutts

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Description: Resident #1 had diagnoses which included severe oral and pharyngeal dysphagia (difficulty swallowing). According to Resident #1’s dietary assessment, staff documented the resident ate a pureed diet with thickened liquids. Facility identified the resident was a risk for choking and the resident exhibited food seeking behaviors. On 7/5/03, the DON passed snacks and at 9:00 p.m. gave a resident a peanut butter and jelly sandwich then continued to pass the rest of the snacks. As she approached the nurses’ station Resident #1 lay on the floor coughing with pieces of food on the ground next to him/her. The DON attempted the Heimlich maneuver and yelled for help. She did not instruct staff to call for an ambulance. Staff took the resident to his/her room and continued to unsuccessfully attempt removal of the blockage. Resident expired at the facility at approximately 9:10 p.m. The DON stated she knew the resident had a Do Not Resuscitate order therefore she did not call 911.

Date of Notice: July 2003

Registered Agent: David Redman

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Description: Facility failed to ensure an accurate measurement of a dietary supplement for six residents and failed to follow professional standards of care related to the intake and output of one resident. Facility failed to implement new interventions for one resident with a significant weight loss and failed to maintain a medication error rate less than 5%. Staff failed to serve the correct amount of food as directed by the menu and failed to provide fluids in the form ordered by the resident’s physician.

Date of Notice: September 2003

Registered Agent: Leigh Hilderbrant

Uncorrected Class II Notice of Noncompliance

Description: Resident #50 was admitted to the facility on 8/12/03 with diagnoses which include a left hip fracture with replacement. Facility documentation showed the resident required moderate assistance and verbal cues with transfers from his/her bed to wheelchair. On 8/27/03, the resident was unable to transfer him/herself from the bed to the wheelchair and as a result was not able to negotiate a path to safety.

Date of Notice: November 2003

Registered Agent: Charlotte Stutts

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Description: Facility staff failed to implement fall prevention interventions and failed to provide close supervision during meal time for one resident at risk for aspiration. Facility also failed to provide food in a manner to meet the requirements of a pureed diet preparation for five of six residents. Facility failed to ensure toxic chemicals were properly secured.

NORTHWEST REGION

Date of Notice: January 2003

None

Uncorrected Class II Notice of Non-Compliance

Description: The facility failed to develop and implement a fire evacuation plan that accounts for all residents’ whereabouts after exiting the building. The facility failed to assure residents smoked only in designated smoking areas. The facility failed to follow physician orders, provide protective oversight for a resident and failed to maintain a safe and effective medication system.

Date of Notice: April 2003

Registered Agent: David C. Furnell

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Description: The facility failed to assure the fire alarm system was operational when the fire alarm was accidentally activated at the beginning of March. Facility staff was not aware the fire alarm was inoperable for approximately three weeks. The facility failed to provide adequate oversight to assure the residents’ safety when staff could not reset the fire alarm, which put ten residents at risk from smoke/fire. Facility staff was not trained on the procedure to reset the fire alarm or assure it was operational. One resident smoked in his/her room. The facility did not have a current license posted and failed to perform quarterly drug regime reviews of resident medications.

Date of Notice: April 2003

Registered Agent: None

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Description: Resident #10 had a history of wandering and elopement attempts at the facility. The resident’s care plan directed staff to visually monitor the resident to ensure the resident remained in the facility and placed a wanderguard on the resident. On 4/5/03, the resident frequently attempted to exit the front door of the facility but staff redirected the resident. At approximately 3:30 p.m., a citizen observed the resident walking on highway 63. The citizen observed a car swerve to miss the resident as he/she walked on the highway. The facility staff were unaware the resident left the facility until they received a phone call. After the resident was returned to the facility, the administrator checked the door alarms and found neither the east nor west door alarms worked.

Date of Notice: April 2003

Registered Agent: Larry G. Schulz

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Description: On 3/25/03 Resident #1 eloped from the facility and was transferred to the local hospital behavioral unit. The hospital discharge treatment plan dated 4/10/03 showed the resident was at risk for elopement, had problems with sleep, verbal aggression and confusion. On 4/14/03 facility staff propped the exit door open and at 7:05 p.m. facility staff discovered Resident #1 was missing from the facility. At 7:30 p.m. the police contacted the facility to see if the facility was missing a resident. The police reported a passerby saw Resident #1 in a ditch. Resident #1 returned to the facility at 8:15 p.m.

Date of Notice: May 2003

Registered Agent: Charlotte Stutts

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Description: On 3/14/03 Resident #1 was restrained in a specialized wheelchair. Facility staff placed the resident in his/her room where the resident could not be readily observed despite a history of dementia, agitation, sliding down in the wheelchair and loosening the seat belt with constant fidgeting. Also, facility staff did not use the restraint features of the specialized wheelchair according to manufacture’s safety guidelines. Facility staff found Resident #1 in his/her specialized wheelchair with the latched seatbelt at the resident’s neck and right armpit area, the resident had expired.

Date of Notice: May 2003

Registered Agent: None

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Description: During the revisit resident was served a bun length hot dog even though the resident had chewing problems and the physician ordered to serve the resident ground meat. The dietary department prepared the tray with the bun length hot dog and the nursing department served the tray to the resident. Both departments knew the resident was to have ground meat.

Date of Notice: June 2003

Registered Agent: Glen Muir

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Description: Facility failed to provide adequate supervision to one resident (Resident #1). The dependent resident was previously found between the bed mattress and the bed rail without apparent injury. At a later time, staff found the resident dead with his/her neck against the vertical bar of the bed rail. Staff did not assess and implement interventions to prevent the recurrence of the precarious position and staff did not follow facility policy for checking and repositioning the resident during the night shift before he/she was found dead.

Date of Notice: June 2003

Registered Agent: Michael A. Insco

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Description: One resident with a history of alcohol and drug abuse, sexual activity, self-mutilation and suicidal tendencies had been adjudicated incompetent. The resident was admitted to the facility with instructions to limit visitors to the guardian, caseworker and parents. Resident had unprotected sexual intercourse with a facility visitor. The owner stated there was no facility failure because the sexual encounter was consensual. Facility cancelled the resident’s scheduled visit to the psychiatrist even though the resident exhibited adverse effects from the antipsychotic medication and voiced suicidal ideations. Facility staff introduced and provided access for the resident to an Internet chat room. The owner stopped the Internet access after phone calls were placed to the resident. The resident was transferred to a crisis center.

Date of Notice: September 2003

Registered Agent: Michael A. Insco

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Description: Facility failed to transcribe and follow a physician order to obtain blood tests for lithium (an anti-psychotic medication) levels on Resident #1. Resident was admitted to the hospital with decreased consciousness and toxic lithium levels. Facility also failed to complete blood tests for lithium and Depakote levels for three additional residents.

Date of Notice: November 2003

Registered Agent: None

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Description: An abbreviated survey was completed 8/27/03. On 10/28/03, a revisit was completed at the above facility. Facility was not in compliance in the area of Quality of Care. Facility failed to thoroughly investigate missing medications of Ultram and Ultraset. Facility staff failed to reconcile 5 residents’ medication administration records for Ultram. Facility staff failed to obtain a physician ordered sputum culture for one resident. Facility staff failed to assess one resident’s increased furosemide (medication to remove excess fluid) and pain medication, decreased fluid and food intake and notify resident’s physician. Also, facility staff failed to evaluate and implement changes in diet when the resident’s weight decreased from 174.2 lbs on 6/5/02 to 107.4 lbs on 10/13/03. Facility staff failed to prevent urinary tract infections or prevent their recurrence by not using aseptic technique when changing leg and catheter drainage bags and storing the bags in an unsanitary environment. Facility administrator and nursing administration failed to investigate missing medications, assure aseptic techniques when changing leg and catheter drainage bags to prevent urinary tract infections or the recurrence. Facility also failed to assess and implement diet changes for one resident with a significant weight loss who received increased lasix and pain medication and notify the resident’s physician. In addition, the facility failed to provide adequate orientation to agency nurses. Facility failed to provide pharmacy services that establish a system of records, receipt and distribution of Ultram and Ultracet for 8 residents (Residents #9, #10, #11, #12, #13, #14, #15 and #16) to ensure an accurate reconciliation and account of all controlled drugs.

SOUTHEAST REGION

The Manor

Date of Notice: April 2003

Registered Agent: Lonnie G. Hasty

Uncorrected Class II Notice of Noncompliance

Description: The facility staff failed to ensure Resident #32 maintained the right to refuse medications. On 3/28/03 facility staff placed medications Resident #32 refused in the resident’s food. The facility did not maintain resident room doors; baseboards in bathrooms and comfortable water temperatures were not maintained. Facility staff did not follow physician orders and maintain acceptable medication administration nor ensure resident’s drug regimen was free from any unnecessary drugs.

Date of Notice: August 2003

Registered Agent: John M. Sells

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Description: Facility failed to maintain an adequate approved surety bond, provide quarterly account statements, notify residents of account balances within $200 of the Medicaid resource limit, reconcile the resident trust fund account monthly or keep records according to generally accepted accounting principles for residents with funds managed by the facility.

Date of Notice: August 2003

Registered Agent: John M. Sells

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Description: Facility failed to maintain an adequate approved surety bond, provide quarterly account statements, notify residents of account balances within $200 of the Medicaid resource limit, reconcile the resident trust fund account monthly or keep records according to generally accepted accounting principles for residents with funds managed by the facility.

Date of Notice: October 2003

Resident Agent: Lonnie G. Hasty

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Description: The facility failed to comply with: Dietary requirements as staff did not provide diets according to physician orders and did not prepare food according to standardized recipes; Food sanitation requirements as staff did not maintain personal cleanliness and did not wash hands during food preparation and service; did not wear hair restraints while in the kitchen; did not store, prepare and serve food in a manner to protect food from contamination; did not hold prepared food at proper temperatures; did not ensure refrigeration units were cooling potentially hazardous foods to the proper temperatures; equipment and utensils were not repaired and were not easily cleanable; did not ensure food contact and non-food contact surfaces were easily cleanable or repaired; did not ensure cleaned equipment, utensils and dishes were handled and stored in a way to prevent contamination; General Sanitation requirements as the facility did not keep the kitchen and dining room free of pests; did not ensure walls and ceilings in the kitchen and refrigeration units were in good condition and cleanable; and failed to keep kitchen floor clean and free of debris.

Date of Notice: December 2003

Registered Agent: John M. Sells

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Description: Facility failed to ensure resident funds were not commingled with the facility’s operating funds and failed to return resident funds to discharged residents within 5 days. Facility did not maintain a written account for each resident, showing receipts to and disbursements from the personal funds of each resident. Facility failed to maintain an adequate surety bond.

SOUTHWEST REGION

Date of Notice: March 2003

Registered Agent: CT Corporation

Uncorrected Class II Notice of Noncompliance

Description: The facility failed to follow physicians’ orders and administer dietary supplements for six residents. The facility also failed to assess a resident’s bowel pattern and administer appropriate medications to address the resident’s constipation. Staff failed to provide restorative services to five residents as directed by physicians’ orders and by resident care plans. Observation of medication administration revealed a medication error rate of 13%.

Date of Notice: April 2003

Registered Agent: Pauline Plummer

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Description: Resident #1 has diagnosis of dementia, Alzheimer’s type with delusions. The resident previously resided at a skilled facility where he/she had a history of elopement. The residential care facility was informed of the resident’s elopement history. The resident left the facility on multiple occasions; however staff failed to increase monitoring to prevent elopement. On 3/18/03, the sheriff’s department called the facility and informed staff the resident was at a car lot in town approximately one mile away. The facility staff were unaware the resident eloped until the sheriff notified staff.

Date of Notice: April 2003

Registered Agent: Pauline Plummer

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Description: The facility admitted a resident with a history of arson and the resident resided on the second floor of the facility. On 3/13/03, the facility suspected the resident attempted to set a mattress on fire on the second floor. After the incident, facility staff was directed to stay upstairs with the resident at all times during the night to monitor the resident. On 3/15/03 at 1:30 a.m. a staff member assigned to monitor the resident left the second floor. Staff heard footsteps in the direction of the resident’s room then the fire alarm sounded. A mattress on the second floor was on fire and the facility suspected the resident set the fire. The facility did not implement any new interventions to monitor the resident and did not ensure the current interventions were implemented.

Date of Notice: April 2003

Registered Agent: C T Corporation System

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Description: The facility failed to ensure water temperatures did not exceed 120 degrees F for eighteen residents on a special care unit. According to the Director of Nursing, all the residents residing on the unit were low functioning mentally and high functioning physically. The water temperatures in resident hand sinks ranged from 126 degrees to 150 degrees F. The facility also failed to ensure employees were not on the EDL prior to resident contact and did not request criminal background checks within two working days. Staff did not annually review resident rights and advanced directives with residents.

Date of Notice: June 2003

Registered Agent: Don Jennings

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Description: Facility failed to ensure the hot water temperature did not exceed 120 degrees F in resident accessible plumbing fixtures. The water temperature measured 175 to 180 degrees F. Ten residents resided in the facility including one resident with dementia and two residents with mental retardation.

Date of Notice: June 2003

Resident Agent: Prentice-Hall Corp. Syst

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Description: On 5/14/03, Resident #1 attempted suicide at another facility after his/her father passed away. The resident was admitted to a psychiatric hospital for treatment and then discharged to Nevada Manor on 5/23/03. The resident exhibited signs of depression and suicide risk factors. The facility failed to implement interventions to address the resident’s symptoms and failed to increase supervision. On 6/1/03, the resident wrapped three cords around his/her neck, tied them to a sprinkler head and hung himself/herself, which resulted in the resident’s death.

Date of Notice: June 2003

Registered Agent: Prentice-Hall Corp. System

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Description: On 5/24/03 at 6:00 p.m., Resident #1 fell in the hall outside the special care unit door. The resident complained of pain throughout the evening and night. Facility staff reported the resident’s complaint of pain to the nurses on duty. The nursing staff did not effectively reassess the resident after the reports of pain and failed to call the resident’s physician until 5/25/03 at 6:30 a.m. The resident sustained a left hip fracture and was admitted to a hospital for treatment.

Date of Notice: October 2003

Registered Agent: Douglas A. Parker

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Description: Facility failed to ensure windows contained window screens and failed to maintain the windows with screens. Facility failed to obtain an annual fire inspection and failed to ensure staff were able to unlock each room from the outside in case of an emergency. Facility did not meet physical plant requirements due to failure to obtain an elevator inspection, improper use of extension cords, loose handrails and an inoperable boiler. Facility did not clean or maintain resident rooms and common rooms in a neat and orderly manner. Facility staff stated they experienced difficulty with obtaining supplies from management which impeded their ability to clean the facility. Facility failed to replace broken, torn and soiled furniture. Criminal background checks and EDL checks were not conducted in a timely manner. Facility failed to provide staff in sufficient numbers in order to maintain the facility and failed to provide care to meet residents’ needs. Facility failed to meet general sanitation requirements as evidenced by dirty walls, windows and doors, stained tile and carpet in disrepair, inoperable light fixtures, plumbing problems and failure to eliminate odors.

Date of Notice: October 2003

Registered Agent: Douglas A. Parker

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Description: Facility failed to repair a malfunctioning fire alarm system for at least two weeks and did not implement a fire watch during that time. Facility staff placed a pencil in the reset switch to prevent fire alarm activation and failed to reset two pull stations.

ST. LOUIS REGION

Date of Notice: January 2003

Registered Agent: Mark C. Goldenberg

Uncorrected Class II Notice of Non-Compliance

Description: Facility failed to correct the following deficiencies: Facility staff stored excessive flammable and combustible materials in a non-protected area, creating a fire hazard; Emergency lights, used to illuminate exit pathways in two wings of the building, did not work; Plumbing fixtures in multiple bathrooms were not in working order.

Date of Notice: January 2003

Registered Agent: Mark A. Shklar

Uncorrected Class II Notice of Non-Compliance

Description: The facility staff failed to correct the deficiencies regarding resident care. Two dependent residents were not properly cleansed after incontinent episodes. Three residents with pressure sores did not have appropriate treatments and pressure relieving devices. One resident, who required two staff for transfers, was transferred by one staff. The staff person could not support the resident alone and lowered the resident to the floor. The resident sustained a broken leg due to the improper transfer.

Date of Notice: January 2003

Registered Agent: Sharo Shirshekan

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Description: The facility staff were aware of a malfunctioning circulating pump and failed to maintain hot water temperatures at a safe level. Staff turned up the thermostat on the water heater, yet failed to adequately monitor temperatures in resident use areas. Ambulatory residents with cognitive impairments had access to hot water up to 150 degrees F.

Date of Notice: February 2003

Registered Agent: C T Corporation System

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Description: The facility failed to provide protective oversight for residents during a fire at the facility. The staff person in charge of the facility told emergency rescue personnel all the residents were evacuated from the facility’s third floor when in fact they were not and did not see that a head count was done following evacuation. Four residents were left in the burning facility and two died from smoke inhalation.

Date of Notice: February 2003

Registered Agent: Tony Curtis

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Description: The facility failed to provide sufficient supervision and assistance to prevent accidents for four residents with history of falls. The facility did not change care plan interventions and did not involve physical therapy personnel in making recommendations to prevent falls. The facility submitted a plan of correction for the 12/05/02 statement of deficiency but the administrator and Director of Nursing were new to the facility within the past two weeks. The new administrative team had not implemented the measures recorded in the plan of correction.

Date of Notice: February 2003

Registered Agent: Mark A. Shklar

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Description: The facility staff failed to appropriately care for one resident dependent upon a ventilator. The facility respiratory therapist attempted to wean the resident off of the ventilation machine without adequate supervision and direction from the resident’s physician. The resident was found unresponsive while off of the ventilator and staff transferred the resident to the hospital. The resident died three days later with the primary cause of death as brain damage. The resident’s physician said the resident was not a candidate to be weaned off of the ventilator and the attempt to wean her off ultimately caused the brain damage.

Date of Notice: March 2003

Registered Agent: Michael Woodard

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Description: Facility failed to: provide quarterly statements to the resident or their legal representative; maintain a system that assured separate accounting of each resident’s personal funds; notify Medicaid recipients when the amount in the account reached $200.00 less than the Social Security Income limit for one person $799.99); prevent residents from having negative balances in the account; use acceptable bookkeeping procedures to determine the amount in the resident’s funds; maintain a surety bond.

Date of Notice: March 2003

Registered Agent: Mark A. Shklar

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Pressure Sore Care: Residents with pressure sores were left wet and soiled for long periods of time, were not given proper incontinence care, were not provided with appropriate treatments and repositioned timely. Activities of Daily Living: Residents who require assistance from staff were left wet and soiled for long periods of time, were not given appropriate incontinence care, and were not repositioned timely in accordance with their written plans of care. Providing Appropriate Wound Care: One resident with skin tears was not given appropriate treatments as ordered by a physician. The wounds were covered with treatments and dressings with no physician’s order. Symptoms of infection in the wounds were not addressed. Staffing: The facility was not staffed with sufficient numbers to meet the needs of the residents.

Date of Notice: March 2003

Registered Agent: Mark Shklar

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Description: Facility staff failed to respond to a medical emergency by not intervening during a resident’s respiratory/cardiac arrest on 2/17/03. Facility staff failed to perform CPR or call 911 for this resident who was a Full Code. The resident expired. There was only one licensed nurse in charge of the entire facility at the time for 173 residents.

Date of Notice: April 2003

Registered Agent: C T Corporation System

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Description: Resident #1 was identified as the facility’s only elopement risk. The resident had left the facility, crossed a highly traveled road and went approximately ¾ of a mile from the facility. The facility had no knowledge the resisdent left until alerted by a SLCR surveyor. The resident’s electronic monitoring bracelet was not working when staff checked it after he/she returned. The facility did not have systems in place to ensure his/her electronic monitoring bracelet did work and that staff were consistently checking it. The resident sustained an abrasion to his/her left hand.

Date of Notice: April 2003

Registered Agent: C T Corporation Syst.

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Description: The facility staff failed to follow physician’s orders regarding residents’ wounds and conduct necessary laboratory tests to determine the residents’ condition. The facility failed to provide residents with the care and services needed to promote the healing of pressure sores and to prevent new pressure sores from developing.

Date of Notice: April 2003

Registered Agent: Mark S. Rubin, Esq.

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Description: The facility staff failed to maintain resident shower and tub rooms in a homelike manner by not maintaining hot water temperatures at acceptable ranges, not maintaining plumbing fixtures and by failing to eliminate storage materials from shower and tub rooms. The facility failed to prevent pressure sores from occurring by not assessing and treating residents at risk of pressure sore development.

Date of Notice: April 2003

Registered Agent: The Corporation Co.

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Description: The facility failed to apply acceptable nursing interventions for a resident who had diabetes mellitus and a dependency for sliding scale insulin. The facility failed to ensure the resident received medications including insulin from 3/17/03 to 3/19/03, even though the resident had elevated blood sugars. The physician was not contacted regarding the elevated blood sugars. On 3/19/03, the resident became unresponsive and had no vital signs. Facility staff did not initiate CPR even though there was a physician’s order to conduct CPR.

Date of Notice: May 2003

Registered Agent: Richard J. Destefane

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Description: The facility to correct the following Class II deficiencies: the hot water temperature for resident use was not a minimum of 105 degrees F; residents did not receive medications as ordered by their physicians; the residents’ environment was not maintained free from accident hazards; one medication room on a locked behavioral unit was not kept locked; the facility did not employ a qualified Social Service employee who was able to provide appropriate services to all residents.

Date of Notice: May 2003

Registered Agent: Husch Registered Agent Inc.

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Description: The facility failed to correct the following deficiencies: facility failed to provide protective oversight for residents. Foods with excessively high temperatures (205 degrees F) were served to residents resulting in third degree burns. The facility failed to investigate and provide prompt medical care to residents with injuries of unknown origin including a fractured kneecap.

Date of Notice: May 2003

Registered Agent: Lonnie G. Hasty

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Description: The facility failed to follow physician orders for providing nutritional supplements, obtaining laboratory tests and providing specialized therapy as ordered. The facility failed to provide the prescribed calories to three residents who received nutrition through a feeding tube. The facility failed to ensure that the temperature of hot foods served to residents is at least 120 degrees during three of three meals.

Date of Notice: June 2003

Registered Agent: Thomas H. Spence

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Description: These conditions involved the facility’s failure to investigate, report and keep residents free from abuse. Three residents reported inappropriate behavior and/or rough treatment by one staff person since 2/26/03. In addition, a resident reported inappropriate sexual behavior on 4/22/03. The facility did not thoroughly investigate or intervene after the alleged incidents occurred. The facility allowed the staff person to continue to work resulting in sexual abuse of one resident.

Date of Notice: July 2003

Registered Agent: Timothy G. Dolan

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Description: Facility failed to assure all residents were capable of making a normal path to safety unassisted. Three residents in the facility were unable to physically and/or mentally exit the building during a fire drill.

Date of Notice: July 2003

Registered Agent: Mark A. Shklar

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Description: Facility failed to conduct a comprehensive fire watch and staff sufficiently to evacuate the building in the event of a fire when the fire alarm system was not functioning. Facility failed to correct the following areas: privacy for residents while administering insulin injections; following physicians’ orders; dispensing medications without a medication error rate.

Date of Notice: August 2003

Registered Agent: David P. Linderer

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Description: Facility failed to correct the following deficiencies: A safe and effective system of medication administration was not implemented. Residents were administered insulin by unqualified persons and medications were passed to multiple residents without proper handwashing/sanitizing. Insulin was not administered in accordance with physician orders.

Date of Notice: August 2003

Registered Agent: Jerryl Christmas

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Description: Facility staff failed to prevent residents from smoking in their resident rooms without direct supervision.

Date of Notice: August 2003

Registered Agent: Charlotte Stutts

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Description: Facility failed to provide a clean and homelike environment for residents and failed to maintain hazardous areas separated by not closing the door to the laundry room. Facility failed to administer pain medication as ordered for one resident and failed to provide necessary care and services to residents at risk for falls to ensure falls and injuries did not occur.

Date of Notice: September 2003

Registered Agent: David P. Linderer

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Description: Facility failed to provide protective oversight for one resident. Resident signed out for several hours and did not return as scheduled. Resident was missing from the facility for several hours beyond his/her expected return, and facility staff were not aware the resident did not return. Facility staff were informed by a law enforcement official of the resident’s whereabouts, some 25 miles away from the facility, during the middle of the night.

Date of Notice: September 2003

Registered Agent: Mark A. Shlkar

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Description: One confused resident eloped from the facility. Facility staff did not know the resident was gone until the police contacted them. When the police first contacted the facility, facility staff denied having a resident missing. During the time the resident was missing from the facility, staff falsely documented the resident was in the building.

Date of Notice: September 2003

Registered Agent: Mary Hickmon

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Description: LCR staff completed an annual inspection on 8/7/03 and a revisit on 9/11/03. At the time of the revisit the facility census was 11. Also at the time of the revisit, the following findings were made. An Uncorrected Class II violation was found in the area of Physical Plant Requirements. Because of the facility’s failure to properly repair water damage to two walls in one resident room occupied by two residents. A new Class II violation was found in the area of Physical Plant Requirements. The facility also failed to ensure the power cords to two emergency lights were protected from damage that could cause a potential safety hazard.

Date of Notice: September 2003

Registered Agent: Mark A. Shklar

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Description: One resident left the facility’s locked behavior unit without the knowledge of staff. Resident has a history of elopements, depression and suicidal ideations/attempts. Resident left the facility unaccompanied by staff to go to a doctor appointment and did not return. Resident was found three days later, walking the city streets.

Date of Notice: December 2003

Registered Agent: Husch Registered Agent, Inc.

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Description: Facility staff failed to properly assess a resident’s change in condition related to a fecal impaction after a compression fracture. Resident began taking a narcotic pain medication with a known side effect of constipation. Facility staff did not monitor resident’s food and fluid intake and output. Resident’s mental and physical condition declined. Resident was not sent to the hospital until the family took her. Resident was found to have fecal impaction and dehydration and died six days later. Physician said the resident’s fecal impaction was a significant contributing factor in the resident’s death.