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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

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.