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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

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.