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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.