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Missouri Long-term Care
Facility Notices of Non-Compliance 2004 |
2004 Nursing Home Non-Compliance by Region: 1. Southwest Region |
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Facility: Laurie Care Center Laurie, MO
60-Bed, Skilled Nursing Facility
Date of Notice: January 2004 |
Owner: Good Shepherd N.H. Dist. 1
Operator: Good Shepherd N.H. Dist. 1
Registered Agent: None Available
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Legal Action: Class I Notice of Noncompliance |
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Description: Facility failed to prevent one resident from leaving without staff knowledge. On 12/28/03 at 7:00 p.m. Resident #1 was found in the middle of a two-lane road with his/her walker by members of the community. The community members observed several cars swerve to avoid hitting the resident, who was wearing dark clothing. |
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Facility: South Hampton Place Columbia, MO
100-Bed Skilled Nursing Facility
Date of Notice: January 2004 |
Owner: Corporate Care Center, Inc. Operator: N&R of South Hampton, LLC Registered Agent: Charlotte Stutts |
Legal Action: Uncorrected Class II Notice of Noncompliance
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Description: Facility was issued a statement of deficiency in the area of professional standards of practice during a complaint investigation on 11/17/03. A revisit to the deficiencies was completed on 1/14/04 and facility was not in substantial compliance with participation requirements. Facility staff failed to document testing of blood sugar levels and the administration of insulin for 7 residents. Facility staff failed to recognize signs and symptoms of urinary tract infections for one resident, who had a recent history of a urinary tract infection, which resulted in falls and behavior changes in the resident. Also, facility failed to provide adequate supervision to prevent accidents for one resident with multiple falls. |
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Facility: Ashland Healthcare Ashland, MO
60-Bed, Skilled Nursing Facility
Date of Notice: March 2004 |
Owner: Noble House of Ashland, Inc. Operator: Ashland Nursing & Rehab, LLC Registered Agent: Charlotte Stutts |
Legal Action: Uncorrected Class II Notice of Non-compliance |
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Description: Facility failed to provide oral care, incontinence care, and failed to provide thorough perineal cleansing for ten residents. |
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Facility: West Village Manor Columbia, MO
120-Bed Skilled Nursing Facility
Date of Notice: March 2004 |
Owner: Astoria Place, LLC Operator: West Village Manor, LLC Registered Agent: Sharo Shirshekan |
Legal Action: Uncorrected Class II Notice of Non-compliance |
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Description: On 1/12/04, as a result of an abbreviated survey the facility was cited a deficiency in the area of professional standards of practice. On 2/23/04 a revisit was completed, the facility failed to administer medications to three residents as ordered by the physician and to administer medications in a timely manner for one resident. Facility also failed to account for controlled narcotics. |
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Facility: California Care Center California, MO 60-Bed Skilled Nursing Facility Date of Notice: April 2004 |
Owner: N & R of California, Inc. Operator: N&R of California, Inc. Registered Agent: Charlotte Stutts |
Legal Action: Uncorrected Class II Notice of Non-compliance |
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Description: A revisit was completed at the facility on 3/23/04 and found the facility had not corrected the deficiencies cited during the survey of 1/30/04. The facility staff failed to administer residents’ medications within the two-hour timeframe and failed to adjust the timing of the next dose of medication resulting in significant medication errors. Also a new deficiency was found in the area of family notification of a significant change in one resident’s condition which required medical intervention. |
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Facility: West Village Manor Columbia, MO 120-Bed Skilled Nursing Facility Date of Notice: April 2004 |
Owner: Bristol Care, Inc. Operator: Bristol Care, Inc. Registered Agent: David C. Furnell |
Legal Action: Uncorrected Class II Notice of Noncompliance |
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Description: Facility failed to document medication administration, assess residents’ conditions and contact resident’s physician to obtain treatment orders and provide the treatment and services. Facility also failed in the following areas: Provide privacy to residents during care; ensure residents are free from restraints; complete criminal background and EDL checks for all employees; store residents’ medications in a manner to ensure the stability and effectiveness of the medication is not altered; provide Range of Motion to residents to maintain/prevent residents’ abilities; provide adequate supervision to prevent falls and accidents; complete significant change MDS when there has been a change in the resident’s condition; provide services to ensure residents admitted without pressure sores do not develop pressure sores; provide activities to meet the needs of the residents; staff assistance with ADLs to dependent residents; develop plans of care to address the resident current needs and assistance; maintain parameters of nutrition to resident experiencing significant weight loss; follow infection control practices; provide sufficient staffing to ensure residents’ care needs are met; ensure nurse aide competency; provide dietary services to ensure food is served at the appropriate temperatures and monitor dietary staff competency and skill to ensure recipes are followed; environment is well maintained and in good repair; Life Safety Code standards are met by ensuring exits are marked and unobstructed; pharmacy services are provided in a timely manner; residents’ clinical records are complete and accurate. |
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Facility: Jefferson Lodge Fulton, MO 94-Bed Residential Care Date of Notice: April 2004 |
Owner: Rescare of Missouri, Inc. Operator: Rescare of Missouri, Inc. Registered Agent: Eric F. Fink, Jr. |
Legal Action: Class I Notice of Non-compliance |
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Description: Facility failed to provide protective oversight for one resident who was sexually assaulted by another resident with a known history of statutory rape. Facility staff did not inform Resident #2’s guardian or mental health care manager that Resident #2 was watching pornographic movies. On 3/29/04 Resident #2 asked Resident #1 into his/her room to watch a movie. When Resident #1 entered the room Resident #2 turned on a pornographic movie and would not allow Resident #1 to return to his/her room resulting in Resident #1 being raped. |
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Facility: Rolla Manor Care Center Rolla, MO 102-Bed Skilled Nursing Facility Date of Notice: June 2004 |
Owner: Rolla Manor, Inc. Operator: Rolla Manor, Inc. Registered Agent: Hal F. Juckette |
Legal Action: Uncorrected Class II Notice of Noncompliance |
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Description: On 5/13/04 an annual survey was completed at the above facility. On 6/22/04 a revisit was completed and found the facility was not in substantial compliance. The facility staff failed to follow up on a dietary recommendation for one resident and to follow physician ordered treatments for two residents. Also the facility failed to provide care and services to prevent falls for one resident. |
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Facility: Cuba Manor, Inc. Cuba, MO 90-Bed Skilled Nursing Facility Date of Notice: August 2004 |
Owner: Cuba Healthcare, Inc. Operator: Cuba Manor, Inc. Registered Agent: Brad Queen |
Legal Action: Uncorrected Class II Notice of Noncompliance |
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Description: On 6/11/04 a survey was completed at the facility. A revisit was completed on 7/22/04. Facility was not in substantial compliance with participation requirements. Facility failed to provide care that met current professional standards for two residents (Residents #10 and #20) whose care was reviewed. Facility staff failed to carry out physician’s orders for a low bed, a personal alarm, one side rail to be in the raised position, and failed to elevate the feet and apply waffle boots for one resident. |
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Facility: Heisinger Lutheran Home Jefferson City, MO 111-Bed Residential Care Facility Date of Notice: August 2004 |
Owner: Cole Co. Lutheran Home Ass’n. Operator: Cole Co. Lutheran Home Ass’n. Registered Agent: Not Listed |
Legal Action: Class I Notice of Noncompliance |
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Description: Facility failed to provide Resident #1, a confused resident residing on the Alzheimers Unit, with sufficient care to prevent the resident from leaving the facility without staff’s knowledge and sustaining injuries. On 7/14/04 sometime after 8:30 p.m., a railroad employee found Resident #1 lying hurt on the railroad tracks and contacted the police. At 9:55 p.m. a local hospital contacted the facility to ask if they were missing a resident. Facility staff discovered the Alzheimer Unit’s courtyard gate was open, which leads to the facility back yard and a wooded area. Wooded area ends with a bluff, which drops off at certain points 50 to 60 feet to the bottom where railroad tracks are located and run along the bottom of the bluff area. |
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Facility: Jefferson Lodge Fulton, MO 94-Bed Residential Care Facility Date of Notice: August 2004 |
Owner: Rescare of Missouri, Inc. Operator: Rescare of Missouri, Inc. Registered Agent: Eric F. Fink, Jr. |
Legal Action: Uncorrected Class II Notice of Noncompliance |
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Description: A licensure inspection was completed at the facility on 4/13/04. Facility was not in substantial compliance at that time. A revisit was completed on 8/18/094. Facility failed to equip backflow devices on six of 22 spray nozzles. Facility failed to ensure exit signs were in place and illuminated on resident use hallways. Facility staff failed to maintain emergency lights in functional working order. Also, facility staff failed to ensure contents of ashtrays were disposed of in a safe manner. |
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Facility: The Bluffs Columbia, MO 132-Bed Skilled Nursing Facility Date of Notice: September 2004 |
Owner: Boone Co. Commission Operator: Boone County Senior Citizen Services Corp. Registered Agent: Cindy Poston |
Legal Action: Class I Notice of Noncompliance |
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Description: Facility failed to provide adequate supervision to prevent accidents when one confused resident (Resident #1) living on the locked Alzheimer’s Unit, left the facility without staff’s knowledge. A community member found the resident standing in the middle of the highway. Also, facility staff failed to assess the cause of a fall and update the plan of care to prevent additional incidents when a completely dependent resident (Resident #2) was found beside the bed on 7/24/04. Staff found resident beside the bed again on 7/26/04 without a pulse or blood pressure. Resident was hospitalized and died the next day. The death certificate listed the cause of death as hypoxic brain injury. |
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Facility: Rest Haven Convalescent & Retirement Home Sedalia, MO 86-Bed Intermediate Care Facility Date of Notice: October 2004 |
Owner: John T. Finely, Inc. Operator: John T. Finley, Inc. Registered Agent: John C. Finley |
Legal Action: Uncorrected Class II Notice of Noncompliance |
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Description: An abbreviated survey was completed on 8/10/04. A revisit was completed on 9/29/04. The facility was not in substantial compliance with participation requirements. The facility failed to provide adequate supervision to prevent accidents. Facility staff failed to assess, develop and implement a plan of care for three residents who had falls to prevent future falls. |
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Facility: Gibbs Care Center Steelville, MO 66-Bed Skilled Nursing Facility Date of Notice: November 2004 |
Owner: Steelville Community Services, Inc. Operator: Same Registered Agent: Kem Schwieder |
Legal Action: Uncorrected Class II Notice of Noncompliance |
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Description: An annual survey was completed at the facility on 9/16/04. A revisit was completed on 11/10/04. The facility was not in substantial compliance with participation requirements. Facility staff failed to accurately follow recipes for ten residents who required pureed diets. Also, the facility staff failed to test the sanitizing rinse used for hand-washing cooking equipment and utensils. |
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Facility: Oak View Skilled Care Jefferson City, MO 65109 120-Bed Skilled Nursing Facility Date of Notice: December 2004Facility |
Owner: HCRI Missouri Properties, LLC Operator: Cathedral Rock of Jefferson City, MO Registered Agent: Anthony J. Soukenik |
Legal Action: Class I Notice of Noncompliance |
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Description: The facility staff failed to maintain hot water temperatures below 120 degrees F, however the facility staff took immediate action to correct the deficiency by replacing the circulatory pump prior to SLTC leaving the building. |
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Facility: Good Shepherd Care Center Versailles, MO 124-Bed Skilled Nursing Facility Date of Notice: December 2004 |
Owner: Good Shepherd N.H. District 1 Operator: Same Registered Agent: Not Listed |
Legal Action: Uncorrected Class II Notice of Noncompliance |
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Description: An annual survey was completed on 11/10/04. A revisit was completed on 12/28/04. The facility was not in substantial compliance with participation requirements. Facility staff failed to provide quarterly assessments for ten residents, which identified the residents current needs every three months and develop a plan of care to meet the residents’ needs. Also, facility staff failed to monitor psychotropic medication use for three residents. |
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Facility: West Village Manor Columbia, MO 120-Bed Skilled Nursing Facility Date of Notice: December 2004 |
Owner: Astoria Place, LLC Operator: West Village Manor, LLC Registered Agent: Sharo Shirshekan |
Legal Action: Uncorrected Class II Notice of Noncompliance |
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Description: An abbreviated survey was completed on 10/8/04. A revisit was completed on 11/23/04. The facility was not in substantial compliance with participation requirements. Facility staff failed to provide care to prevent the development of urinary tract infections for two residents by not ensuring foley catheter tubing and bags remained off the floor. |
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Facility: Meramec Sunrise Residential Care Rolla, MO 16-Bed Residential Care Facility Date of Notice: December 2004 |
Owner: UK Operator: Meramec Sunrise Residential Care, LLC Registered Agent: David M. Pilotte |
Legal Action: Uncorrected Class II Notice of Noncompliance |
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Description: An annual inspection was completed on 10/13/04. A revisit was completed on 12/2/04. The facility staff failed to ensure doors to hazardous areas are kept closed. Also, facility staff failed to ensure doors between the kitchen and resident use living area are kept closed. |
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Facility: Benton House Kansas City, MO
33-Bed Residential Care Facility
Date of Notice: February 2004 |
Owner: K C Care Corp, c/o Hopkins & Howard Operator: Benton House, LLC Registered Agent: George E. Kapke |
Legal Action: Uncorrected Class II Notice of Noncompliance |
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Description: Complaint investigation and relicensure inspection was completed on 11/3/03 and deficiencies were cited. A revisit was completed on 2/2/04 with deficiencies cited in the following areas: Fire Safety Standards: Facility failed to provide a metal 3-story fire escape; ensure 2 locked exit doors did not require use of a key or tool to unlock the doors; provide 2 remote exits (that do not require a path through a hazardous area) in the basement where the resident dining room is located; ensure all sprinkler heads remained free of any obstruction that could inhibit or prevent their function. Physical Plant Requirements: Facility failed to maintain resident-use mattresses in good repair; maintain safe water temperatures in all resident-use areas. Administrative, Personnel and Resident Care Requirements: Facility failed to administer medication according to physician orders; ensure all physician orders (verbal and telephone orders) are signed by the physician within 7 days. Resident Rights: Facility failed to ensure complete records were kept for all residents; provide at least a 30-day advanced notice before discharge. |
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Facility: Blaiz Boarding Home Kansas City, MO
14-Bed Residential Care Facility
Date of Notice: February 2004 |
Owner: Jill Jones Operator: Lorrie Ackley Registered Agent: Not Listed |
Legal Action: Class I Notice of Noncompliance |
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Description: Facility failed to maintain one of two exit doors did not require special effort to open. The door was secured in a closed and locked position by a hook and eye and a piece of insulated wire with multiple wraps and tied around a large screw. Also, the facility failed to assure there was a complete and functional fire alarm system or individual smoke detectors in all resident rooms, corridors, stairwells, kitchen and furnace room. Facility fire alarm was out of service from 1/24/04 through at least 1/29/04. The owner was aware the fire alarm was not functioning, however she did not implement a fire watch or immediately notify DHSS when the fire alarm was out of service. This placed the 11 residents residing at the facility at risk from fire and smoke. |
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Facility: Golden Years Harrisonville, MO
132-Bed, Skilled Nursing Facility
Date of Notice: February 2004 |
Owner: Deaconess Long Term Care of MO, Inc. Operator: Same Registered Agent: The Corporation Co. |
Legal Action: Class I Notice of Non-Compliance
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Description: Facility failed to provide appropriate treatment and services to correct the assessed problem for a resident who displays mental or psychosocial adjustment difficulty (F319). Facility did not assess, monitor and develop interventions in a timely manner for one resident with psychiatric diagnoses and behaviors and deterioration in his/her mental status. Resident also takes medication for a seizure disorder and is legally blind. Resident had a guardian but on 1/21/04 signed himself/herself out and left the facility at about 3:30 p.m. Facility staff were unaware of the resident’s absence until about 7:15 p.m. Resident remains missing as of 1/27/04. |
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Facility: Maywood Terrace Living Center Independence, MO 89-Bed Skilled Nursing Facility Date of Notice: May 2004 |
Owner: Independence #1 Inc. Operator: Stroetker Diversified, Inc. Registered Agent: Michael J. Gleason |
Legal Action: Uncorrected Class II Notice of Noncompliance |
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Description: At the time of the revisit on 4/29/04, facility failed to correct all deficiencies and was also cited with a new deficiency as follows: Facility did not have a safe and effective medication system, as staff did not administer medication according to physician orders (uncorrected). Facility nursing staff did not administer medication according to acceptable standards of nursing practice (uncorrected). Facility did not provide an audible call light system in the facility’s locked unit (uncorrected). Facility failed to ensure 1 of 2 whirlpool tubs was maintained in working order (uncorrected). Once one resident developed pressure sores, facility failed to provide appropriate care and services to promote healing of the pressure sores. |
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Facility: White Oak Manor Kansas City, MO 150-Bed Skilled Nursing Facility Date of Notice: May 2004 |
Owner: White Oak Manor Operator: White Oak Manor, LLC Registered Agent: Sharo Shirshekan |
Legal Action: Class I Notice of Non-compliance |
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Description: Facility failed to provide adequate supervision to prevent two residents from eloping from the facility. On 4/24/04 at approximately 7:45 p.m. a door located on the SCU alarmed and staff found a resident pushing on the door. Staff removed the resident from the door and reset the alarm. Resident #1 was found four blocks from the facility by a community member standing in the middle of the street talking to him/herself. The community member took the resident to a police officer in the area. Resident #2 was found by a community member 2-1/2 blocks from the facility and taken to the police station. |
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Facility: Villa Ventura Residential Care Facility Kansas City, MO 50-Bed Residential Care Facility Date of Notice: May 2004 |
Owner Gemini Villa Ventura, LLC Operator: Gemini Villa Ventura, LLC Registered Agent: C T Corporation System |
Legal Action: Uncorrected Class II Notice of Noncompliance |
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Description: On 3/25/04 a licensure inspection was completed. A revisit was completed on 5/10/04 and found two residents unable to mentally and physically negotiate a path to safety. At 10:57 a.m., the fire alarm sounded. Resident #5 left her room, but remained in the hallway stating to the DON she was unsure of where to go or what to do. Resident #5 remained in the hallway the three minutes the fire alarm sounded. Resident #6 told staff she heard the fire alarm and didn’t want to go. Resident #6 never left her room the three minutes the fire alarm sounded. |
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Facility: Golden Acres Independence, MO 16-Bed Residential Care Facility Date of Notice: June 2004 |
Owner: Jill Jones Operator: Teresa Henry Registered Agent: Not Listed |
Legal Action: Uncorrected Class II Notice of Noncompliance |
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Description: On 4/20/04 a licensure inspection was completed. A revisit was completed on 5/27/04 and showed the facility failed to address the following violations: Facility staff failed to prevent the storage of unnecessary combustibles in the basement. Facility staff failed to prevent the use of a portable space heater within a resident room. Facility staff failed to maintain personnel records for two employees, ensure employees were not listed on the EDL, failed to obtain criminal background checks on employees and maintain a record of actual hours worked by each employee. Facility staff failed to ensure one resident was physically and mentally able to negotiate a path to safety. Facility staff failed to obtain written approval from a physician for two residents to be readmitted to the facility. Facility failed to obtain a review by a pharmacist or registered nurse of the drug regime review of each resident at least quarterly. |
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Facility: The Oaks Kansas City, MO 30-Bed Residential Care Facility Date of Notice: June 2004 |
Owner: Jeffrey & Laura Forster Operator: Tall Timbers, LLC Registered Agent: Gordon Goodman |
Legal Action: Uncorrected Class II Notice of Noncompliance |
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Description: At the revisit the facility had failed to correct violations cited at the inspection on 4/14/04 as follows: Facility failed to obtain laboratory tests as ordered by the physician. Facility failed to follow physician orders and administer medication as ordered. |
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Facility: Masonic Home of Missouri Kansas City, MO 40-Bed Residential Care Facility Date of Notice: June 2004 |
Owner: Masonic Home of Missouri Operator: Same Registered Agent: Not Listed |
Legal Action: Class I Notice of Noncompliance |
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Description: Facility failed to comply with the National Fire Protection Ass’n requirements and standards for oxygen storage. On 6/9/04 Resident #1 had liquid oxygen stored in his/her closet with combustible materials without ventilation. Facility staff failed to develop or implement policies and procedures for the storage or transference of the liquid oxygen. |
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Facility: Senior Estates Kansas City, MO 107-Bed Skilled Nursing Facility Date of Notice: July 2004 |
Owner: Deaconess Long Term Care of MO, Inc. Operator: Deaconess Long Term Care of MO, Inc. Registered Agent: The Corporation Company |
Legal Action: Class I Notice and Uncorrected Class II Notice of Noncompliance |
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Description: Facility failed to follow their policy to assess, care plan and provide intervention for two residents (Resident #201 and #202) who displayed inappropriate sexual behaviors and for one resident (Resident #200) who displayed multiple behavioral problems. Facility also failed to report inappropriate sexual contact to the Department of Health and Senior Services and proper authorities. Facility failed to maintain the residents’ environment clean and orderly. |
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Facility: IHS of KC at Alpine North Kansas City, MO 186-Bed Skilled Nursing Facility Date of Notice: July 2004 |
Owner: Meditrust Co., LLC Operator: HIS of Cliff Manor, Inc. Registered: National Corporate Research |
Legal Action: Uncorrected Class II Notice of Noncompliance |
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Description: An abbreviated survey was completed on 5/20/04. A revisit was completed on 6/3/04, which found the facility was not in substantial compliance. A second revisit was completed on 7/6/04. Facility staff failed to inform one resident’s physician of stat laboratory results in a timely manner, notify the physician of the resident’s continued elevated temperature and record medications administered on the medication administration record. |
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Facility: Johnson County Care Center Warrensburg, MO 87-Bed Intermediate Care Facility Date of Notice: August 2004 |
Owner: RJ Marvine, Inc. Operator: Leisure Care Corp. Registered Agent: Gary Marvine |
Legal Action: Uncorrected Class II Notice of Noncompliance |
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Description: The annual inspection was completed on 6/1/04. On 7/27/04, the revisit was completed and the facility was not in compliance based on uncorrected Class II in the area of Administration and Resident Care Requirements and new Class II violations in General Sanitation Requirements. The census was 85 residents. Facility failed to: Have a safe and effective system of medication administration as staff prepared multiple syringes with different doses of insulin and did not identify which syringe was for a particular resident before administering the insulin (Uncorrected Class II); provide restorative nursing services according to physician orders (Uncorrected Class II); ensure facility was free of pests. On 7/27/04 a bat was found flying around the third floor where 42 residents resided. Bat was found in a resident occupied room and killed. The dead bat was turned over to Department of Health and Senior Services staff for rabies testing. |
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Facility: Cedar Valley Health Center Raytown, MO 154-Bed Skilled Nursing Facility Date of Notice: August 2004 |
Owner: Missouri Regency Associates Ltd. Operator: Deaconess Long Term Care of MO, Inc. Registered Agent: The Corporation Company |
Legal Action: Uncorrected Class II Notice of Noncompliance |
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Description: Facility was not in compliance with the following requirements. Administration and Resident Care requirements as facility staff did not follow physician orders. Dietary requirements as facility staff did not provide therapeutic diets to residents with nutritional problems and failed to follow recipes during food preparation. Food Service Sanitation requirements as facility staff failed to store, prepare, distribute and serve food under sanitary conditions, failed to clean and maintain food service equipment and food contact and non-food contact food surfaces; and failed to keep kitchen free of flies. General Sanitation requirements as facility staff failed to dispose of garbage and refuse properly. |
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Facility: Glennon Place Nursing Center Kansas City, MO 120-Bed Skilled Nursing Facility Date of Notice: September 2004 |
Owner: Encore Nsg Ctr Ptrs Ltd-85 Operator: Beverly Enterprises-Missouri, Inc. Registered Agent: Prentice-Hall Corporation System |
Legal Action: Uncorrected Class II Notice of Noncompliance |
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Description: Facility failed to provide supervision for one resident identified at risk for falls. Staff left the resident unsupervised in the bathroom. Resident tried to stand unassisted and fell. An X-ray showed resident had a fractured upper left arm. |
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Facility: Ridge Crest Nursing Center Warrensburg, MO 120-Bed Skilled Nursing Facility Date of Notice: October 2004 |
Owner: DCB Real Estate Partnership, LP Operator: Warresnburg #1, Inc. Registered Agent: Lonnie G. Hasty |
Legal Action: Class I Notice of Noncompliance |
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Description: A survey was completed on 10/5/04. Class I violations presenting an imminent danger to the health, safety and welfare of residents in the facility were found in the areas of physical and mental abuse, protective oversight and staffing. The facility failed to ensure residents were free of abuse when administrative staff denied one resident’s request to call “the state” and the resident became angry and staff obtained permission of the guardian to transfer the resident to the behavior unit. Without allowing the resident an opportunity to calm down, staff physically restrained the resident using inappropriate techniques that resulted in bruising of the resident’s arms. Another resident was “taken down” to the floor and held in a manual restraint to control the resident’s behavior. The facility failed to implement policies of abuse prevention, physical restraints and managing residents with behaviors. One resident requested sex from other residents, exhibited violent verbal and physical outbursts, made inappropriate sexual comments to other residents, fondled residents and attempted to hit other residents. The facility failed to assure there was a sufficient number of staff adequately trained to meet the mental and psychosocial needs and assure the safety of residents on the locked behavioral unit. |
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Facility: Monterey Park Nursing Center Independence, MO 122-Bed Skilled Nursing Facility Date of Notice: October 2004 |
Owner: Acorn Health Centers, Inc. Operator: Monterey Park Nursing Center, Inc. Registered Agent: Joseph C. Tutera |
Legal Action: Uncorrected Class II Notice of Noncompliance |
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Description: The annual inspection was completed on 6/21/04 and the revisit was completed on 9/21/04. The facility was not in substantial compliance due to uncorrected violations in the areas of: Physical Plant requirements as the facility failed to ensure all smoke dampers functioned properly when tested. Administration and Resident Care requirements as staff failed to follow nursing standards of practice in administering medication, failed to provide oral care to residents, failed to provide pressure relieving devices for residents with pressure sores, failed to provide appropriate catheter care to prevent urinary tract infections and failed to perform safe transfers of residents at risk for falls and/or injuries. Kitchen Sanitation requirements as staff failed to store food to protect against cross contamination, failed clean and maintain food service equipment, food contact surfaces and failed to use good personal hygiene practices (wearing hair restraints and hand washing). |
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Facility: Jefferson Health Care Lee’s Summit, MO 120-Bed Skilled Nursing Facility Date of Notice: October 2004 |
Owner: The DCB Real Estate Partnership Operator: Jefferson Health Care, Inc. Registered Agent: Lonnie G. Hasty |
Legal Action: Uncorrected Class II Notice of Noncompliance |
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Description: During the revisit and complaint investigation of 9/17/04, the facility was not in compliance due to uncorrected and new deficiencies. The facility failed keep resident rooms, resident use bathrooms, dining rooms and the kitchen clean and maintained. The facility failed to implement its infection control program. The facility failed to investigate and properly treat residents and staff diagnosed with scabies and failed to implement procedures to prevent the spread of scabies to other residents and staff. |
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Facility: Benton House, LLC Independence, MO 33-Bed Residential Care Facility Date of Notice: November 2004 |
Owner: K C Care Corp, c/o Hopkins & Howard Operator: Benton House, LLC Registered Agent: George E. Kapke |
Legal Action: SURRENDER OF PROBATIONARY LICENSE EFFECTIVE 11/3/2004 |
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Facility: Oak Grove Nursing and Rehabilitation Oak Grove, MO 90-Bed Skilled Nursing Facility Date of Notice: December 2004 |
Owner: Grove-Oak-Cal Assoc. LP Operator: N & R of Oak Grove, LLC Registered Agent: Charlotte Stutts |
Legal Action: Uncorrected Class II Notice of Noncompliance |
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Description: At the revisit on 12/13/2004, the facility failed to have a functional fire alarm system to accurately notify the facility and the fire department of a fire emergency affecting the entire building and all the residents in the facility. In addition, facility staff failed to follow physician orders. Staff did not give medication to one resident and gave another resident medication that was not ordered. The resident census at the time of the revisit was 83 residents. |
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Facility: Glennon Place Apartments Kansas City, MO 46-Bed Residential Care Facility Date of Notice: December 2004 |
Owner: Encore Nsg Ctr Ptrs Ltd-85 Operator: Beverly Enterprises-Missouri, Inc. Registered Agent: Prentice-Hall Corporation System |
Legal Action: Class I Notice of Noncompliance |
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Description: On 11/19/04, staff found Resident #1 submerged under water in the bathtub. Staff did not assess for vital signs and did not initiate emergency procedures including CPR. The resident was taken to a local emergency room and later pronounced dead. The resident’s medical record did not contain any signed documentation or physician orders that directed staff to withhold CPR. |
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Facility: Ridge Crest Nursing Center Warrensburg, MO 120-Bed Skilled Nursing Facility Date of Notice: December 2004 |
Owner: DCB Real Estate Partnership, LP Operator: Warrensburg #1, Inc. Registered Agent: Lonnie G. Hasty |
Legal Action: Class I Notice of Noncompliance |
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Description: The facility failed to provide twenty-four hour protective oversight and supervision and failed to provide nursing care in accordance with resident’s condition. Facility staff failed to assess one resident’s behaviors including increased agitation, pacing and paranoia, delusions and hallucinations. The facility failed to assess, develop and implement a plan of care addressing these behaviors, failed to monitor for behavior changes and failed to inform the physician of those changes. The resident eloped from the facility without staff knowing. The resident was found approximately six to seven miles from the facility on a highway and returned to the facility by the Sheriff’s Department. Facility staff failed to adequately supervise three residents who resided on the locked behavior unit who were at risk for eloping from the facility and failed to notify the physician when one resident did elope. One resident eloped without staff knowledge, through a window and was found by staff on their way to work approximately two miles from the facility on a highway. The second resident eloped and was found approximately six miles from the facility. The third resident exhibited exit-seeking behaviors and broke out a window of the dining room. |
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Facility: Moberly Nursing & Rehab Moberly, MO
120-Bed Skilled Nursing Facility
Date of Notice: January 2004 |
Owner: Ravenwood Manor Homes, Inc. Operator: N&R of Moberly, Inc. Registered Agent: Charlotte Stutts |
Legal Action: Class I Notice of Noncompliance
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Description: A Licensed Practical Nurse (LPN) abused and injured four residents between 1/1/04 and 1/5/04. After facility was notified of the initial allegations on 1/1/04, they failed to conduct a thorough investigation and failed to report the allegations to the administrator or Department of Health and Senior Services. On 1/4/04 and 1/5/04, the LPN abused and injured two more residents. Facility did not report or conduct a thorough investigation into the additional abuse allegations. |
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Facility: Bristol Manor of Elsberry Elsberry, MO
12-Bed Residential Care Facility
Date of Notice: February 2004 |
Owner: Bristol Care, Inc. Operator: Same Registered Agent: David C. Furnell |
Legal Action: Uncorrected Class II Notice of Noncompliance |
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Description: Facility failed to administer medication as prescribed for one resident and failed to obtain blood sugars for two residents as ordered by physician. Facility failed to monitor a resident’s whereabouts during periods of substance abuse, failed to notify the resident’s physician about the resident’s substance abuse and failed to notify the physician regarding the resident’s refusal to take his/her medication. Facility failed to serve a no concentrated sweets (NCS) diet as ordered, failed to develop a menu for a NCS diet, and failed to arrange for the services of a dietary consultant. Facility did not keep evacuation routes clear of excessive amounts of snow, ice, weeds and grass and failed to request an annual consultation from the local fire department. |
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Facility: Loma Linda Health Care, Inc. Moberly, MO
96-Bed Skilled Nursing Facility
Date of Notice: March 2004 |
Owner : Loma Linda Health Care, Inc. Operator: Same Registered Agent: Leonard L. Fish |
Legal Action: Uncorrected Class II Notice of Non-compliance |
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Description: Facility failed to ensure a special locking device on the front entrance/exit door, released within 15 seconds of constant pressure. Facility also failed to ensure one nurse aide, who worked at the facility on a full time basis for more than four months, completed a training and competency program. |
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Facility: Bristol Manor of Monroe City Monroe City, MO
12-Bed Residential Care Facility
Date of Notice: March 2004 |
Owner: Bristol Care, Inc. Operator: Same Registered Agent: David C. Furnell |
Legal Action: Class I Notice of Noncompliance |
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Description: Facility staff failed to identify and correct faults in the fire alarm system, failed to immediately notify the Section for Long Term Care regarding the inoperative fire alarm and failed to implement a fire watch after staff discovered the fire alarm problem. |
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Facility: Bristol Manor of Brookfield Brookfield, MO
12-Bed Residential Care Facility
Date of Notice: March 2004 |
Owner: Bristol Care, Inc. Operator: Same Registered Agent: David C. Furnell |
Legal Action: Uncorrected Class II Notice of Non-compliance |
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Description: Facility failed to provide an awake attendant during the night-time hours for five residents who required a walker for ambulation. Facility also failed to notify the physician for one resident with low or elevated blood sugars. Facility staff failed to use acceptable medication administration technique and did not accurately follow physician’s orders. |
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Facility: Macon Health Care Center Macon, MO
120-Bed Skilled Nursing Facility
Date of Notice: March 2004 |
Owner: Health Care Realty LP Operator: Medical Management of Macon, Inc. Registered Agent: Prentice Hall Corp. System |
Legal Action: Class I Notice of Noncompliance |
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Description: Facility assessed Resident #1 with completely limited sensory perception including unresponsive to painful stimuli. Resident #1’s diagnoses included quadriplegia. On 3/3/04, resident complained of back pain and a facility LPN applied a hydrocollator pack to the resident’s lower back without a physician’s order for the treatment. Facility transferred resident to the hospital and the hospital staff discovered deep partial thickness burns on the resident’s mid back as a result of the hydrocollator pack. On 3/5/04, water in hydrocollator measured 172 degrees Fahrenheit. The operation manual recommended a water temperature between 160 and 166 degrees F with a warning the water scalding temperature is 120 degrees F. Facility did not have a system in place to monitor water temperatures and the facility LPN did not know the facility policy regarding hot packs. |
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Facility: Moberly Nursing & Rehab Moberly, MO 120-Bed Skilled Nursing Facility Date of Notice: May 2004 |
Owner: Ravenwood Manor Homes, Inc. Operator: N&R of Moberly, Inc. Registered Agent: Charlotte Stutts |
Legal Action: Uncorrected Class II Notice of Noncompliance |
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Description: Facility failed to provide effective assistance with personal hygiene and oral hygiene. Facility failed to ensure residents received treatment and services to prevent pressure sore development and/or encourage healing. Facility staff failed to utilize safe techniques during resident transfers and failed to maintain a medication error rate less than five percent. Staff failed to utilize effective infection control practices when providing resident care. |
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Facility: Moberly Nursing & Rehab Moberly, MO 120-Bed Skilled Nursing Facility Date of Notice: June 2004 |
Owner: Ravenwood Manor Homes, Inc. Operator: N&R of Moberly, Inc. Registered Agent: Charlotte Stutts |
Legal Action: Uncorrected Class II Notice of Noncompliance |
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Description: Facility failed to administer ordered medication and assess weekly blood pressures for one resident and failed to provide appropriate incontinence care to one resident. In addition, the facility had a 14.6% medication error rate. |
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Facility: Lincoln Co Nursing & Rehab Troy, MO 90-Bed Skilled Nursing Facility Date of Notice: July 2004 |
Owner: Troy Healthcare Center, Inc. Operator: N&R of Moberly, Inc. Registered Agent: Charlotte Stutts |
Legal Action: Uncorrected Class II Notice of Noncompliance |
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Description: Facility staff failed to complete a significant change assessment for one resident following a major decline in his/her physician condition. Facility also failed to follow physician’s orders for one resident when staff did not apply an immobilizer as ordered for a fractured leg. Facility did not provide assistance for one resident to maintain good hygiene and failed to provide transfer equipment according to manufacturer guidelines for residents who required Hoyer lift transfers. |
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Facility: Moberly Nursing & Rehab Moberly, MO 120-Bed Skilled Nursing Facility Date of Notice: August 2004 |
Owner: Ravenwood Manor Homes, Inc. Operator: N&R of Moberly, Inc. Registered Agent: Charlotte Stutts |
Legal Action: Uncorrected Class II Notice of Noncompliance |
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Description: Facility failed to administer medications according to physician’s orders which resulted in a medication error rate of 16%. |
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Facility: Westview Nursing Center Center, MO Date of Notice: September 2004 |
Owner: BNH Enterprises, Inc. Operator: BKY, Inc. Registered Agent: Brandon York |
Legal Action: Uncorrected Class II Notice of Noncompliance |
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Description: Facility failed to hold one resident’s medication as ordered and failed to correctly transcribe a medication order to the resident’s medication administration record which resulted in incorrect medication administration for one resident. Facility failed to hold medication as ordered prior to a diagnostic procedure for one resident. Facility staff failed to store, prepare and serve food to prevent contamination and failed to wash their hands to prevent cross contamination. |
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Facility: Maple Lawn Nursing Home Palmyra, MO 140-Bed Skilled Nursing Facility Date of Notice: October 2004 |
Owner: Marion County Nursing Home District Operator: Healthcare Consultants of Mid-MO, Inc. Registered Agent: Sue Braun |
Legal Action: Class I Notice of Noncompliance |
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Description: On 9/14/04, Resident #1 fell and hit the back of his/her head and sustained a 2-3 cm raised area. At 12:30 p.m. the resident complained of a headache and staff administered Tylenol. The charge nurse was notified of the resident’s complaints of a headache. The charge nurse did not perform a neurological assessment, notify the physician or follow up with the resident. At 2:30 p.m., a hospitality aide found the resident partially on the bed and partially on the chair. The resident exhibited slurred speech, no handgrips, facial drooping and sluggish pupils. The resident was transferred and admitted to the hospital with a diagnosis of subdural hematoma and expired on 9/15/04. |
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Facility: Luther Manor Retirement & Nursing Ctr. Hannibal, MO 60-Bed Skilled Nursing Facility Date of Notice: October 2004 |
Owner: Luther Manor Ass’n. Operator: Luther Manor Ass’n. Registered Agent: Sharon K. Moore |
Legal Action: Class I Notice of Noncompliance |
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Description: On 9/22/04 at 12:15 a.m. staff found Resident #1 on the floor in his/her room. Between 12:15 a.m. and 7:00 a.m., the resident’s level of consciousness diminished, the resident became nauseated and the resident was unable to walk. During this time, assessments were delayed, not performed or incomplete. At 7:00 a.m., staff documented the resident was unable to reposition self in bed, nauseated, skin damp and warm, complained of being hot, O2 Sat 73% on 2L of O2 increased to 90% on 5L of O2. Facility staff failed to notify the physician regarding the resident’s condition. At 8:30 a.m., the staff documented the resident’s blood pressure as 70/50, pulse 60 and thready, respirations 28 and staff notified the physician. The resident was sent to the hospital and diagnosed with massive intracranial hemorrhage (bleeding in the brain) and a pelvic fracture. |
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Facility: Loma Linda Health Care, Inc. Moberly, MO 96-Bed Skilled Nursing Facility Date of Notice: October 2004 |
Owner: Loma Linda Healthcare, Inc. Operator: Loma Linda Healthcare, Inc. Registered Agent: Leonard L. Fish |
Legal Action: Class I Notice of Noncompliance |
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Description: The facility failed to follow physician’s orders received on 9/24/04 to discontinue a narcotic analgesic for one resident (Resident #1) who was lethargic and had a decreased level of consciousness. The facility discontinued the medication on 9/27/04 but did not notify the physician regarding the delay or regarding the resident’s condition until 9/29/04. The facility transferred the resident to the hospital on 9/29/04 and the resident expired on 10/6/04. According to the physician, the resident did not eat or drink for an extra three to four days because the facility failed to discontinue the medication as ordered. The death certificate listed the cause of death as sepsis, UTI and dehydration. |
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Facility: Elderhaus Inn Troy, MO 20-Bed Residential Care Facility Date of Notice: October 2004 |
Owner: Boden, Robert & Penny Operator: Robert Boden Registered Agent: None |
Legal Action: Uncorrected Class II Notice of Noncompliance |
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Description: The facility failed to maintain one-hour separation in the furnace room and did not maintain facility floors in good repair. The facility also failed to obtain CBC and EDL checks for two employees prior to resident contact. |
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Facility: Life Care Center of Brookfield Brookfield, MO 120-Bed Skilled Nursing Facility Date of Notice: November 2004 |
Owner: Brookfield Medical Investors, LLC Operator: Same Registered Agent: C T Corporation System |
Legal Action: Class I Notice of Noncompliance |
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Description: On 8/29/04 at 2:00 a.m. and throughout the day, Resident #1 complained he/she did not feel well, experienced nausea, diaphoresis, elevated blood pressure, loose stools, lethargy and required more assistance with transfers. Facility staff did not conduct a full assessment of Resident #1 and failed to notify the resident’s physician regarding the resident’s change in condition. On 8/30/04, the resident continued to complain eh/she did not feel well. Staff documented the resident was weak, required more assistance with transfers, leaned to the right, and was diaphoretic. The facility notified the physician and staff transferred the resident to the hospital. Admission diagnoses included bowel obstruction and the resident expired on 8/31/04. |
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Facility: Silex Community Care Silex, MO 60-Bed Skilled Nursing Facility Date of Notice: November 2004 |
Owner: Silex Care, Inc. Operator: N&R of Silex, Inc. Registered Agent: Charlotte Stutts |
Legal Action: Class I Notice of Noncompliance |
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Description: On 7/4/04, the facility failed to notify one resident’s physician regarding the resident’s lethargy and a change in his/her urine. The facility failed to notify the resident’s physician regarding abnormal urinalysis results in a timely manner and failed to report the resident’s condition decline including decreased intake. On 7/9/04, the staff documented the resident was unresponsive to verbal stimuli but failed to notify the resident’s physician at that time. At 12:00 p.m., the facility called the physician but failed to communicate all of the resident assessment findings. The resident’s condition continued to decline and the resident was transferred to the hospital on 7/10/04. Hospital diagnoses included renal failure, urinary tract infection, diabetic ketoacidosis, and extreme dehydration. The resident expired at the hospital with a cause of death documented as metabolic encephalopathy (a neurological disturbance which may occur due to hypoxia, ischemia or other organ diseases), hyperosmolar ketotic diabetic coma (can occur as a result of extremely high blood glucose levels, decreased consciousness, and extreme dehydration) and uncontrolled diabetes mellitus. |
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Facility: Maple Lawn Nursing Home Palmyra, MO 140-Bed Skilled Nursing Facility Date of Notice: December 2004 |
Owner: Marion County Nursing Home District Operator: Same Registered Agent: Not Listed |
Legal Action: Class I Notice of Noncompliance |
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Description: The facility staff failed to maintain hot water temperatures below 120 degrees F, however the facility staff took immediate action to correct the deficiency by replacing the mixing valve on the hot water heater prior to SLTC leaving the building. |
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Facility: Milan Health Care Facility Milan, MO 100-Bed Skilled Nursing Facility Date of Notice: December 2004 |
Owner: B & F Partnership Operator: N & R of Milan, Inc. Registered Agent: Charlotte Stutts |
Legal Action: Class I Notice of Noncompliance |
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Description: The facility staff provided one resident with a sandwich, which was not the appropriate consistency. Although the resident had a history of eating too fast and choking, the staff did not supervise the resident while he/she ate the sandwich. The facility staff failed to provide the resident the appropriate care during the choking incident. The resident subsequently died of aspiration with cardiopulmonary arrest. |
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Facility: Superior Park Assisted Living Excelsior Springs, MO
66-Bed Residential Care Facility
Date of Notice: March 2004 |
Owner: DST, Inc. Operator: Same Registered Agent: Thomas A. Walker |
Legal Action: Class I Notice of Noncompliance
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Description: Facility staff knowingly failed to act and perform a duty in a manner which would not adversely affect a resident’s health. On 2/8/04 at 3:15 a.m., staff discovered 4 empty packages of ephedrine (92 tablets) under Resident #1’s, who was known to abuse the drug, mattress cover and failed to intervene for more than one hour. At 4:30 a.m. 3 staff certified in CPR witnessed Resident #1 in cardiac arrest and failed to perform CPR when a breathing mask was not found due to rumors of Resident #1 being promiscuous with drug users. |
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Facility: Citadel Health Care St. Joseph, MO 100-Bed Skilled Nursing Facility Date of Notice: April 2004 |
Owner: Diamond Health Care Corp. Operator: Citadel Holdings, LLC Registered Agent: Jeffrey K. Phillips |
Legal Action: Uncorrected Class I Notice of Noncompliance |
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Description: On 2/9/04 a survey was completed at the facility. A revisit was completed on 4/9/04 and found the facility was not in substantial compliance3 with participation requirements in the areas of: Professional standards of practice when staff failed to follow physician orders for one resident who had a fall resulting in pain and staff failed to administer the pain medication; Provide services in accordance with the residents plan of care for one resident whose plan of care directed staff to place the resident in a wheelchair utilizing a self-releasing safety device was placed in a geriatric chair; Supervision to prevent accidents – staff failed to implement interventions to prevent falls for one resident when staff left the resident unattended in a wheelchair. Resident fell forward striking his/her head on the concrete floor resulting in bruising and skin tears; Infection Control Practices – facility failed to ensure staff washed their hands when moving from soiled to clean areas during resident care; Safe, functional sanitary environment – facility |
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Facility: Crestview Home, Inc. Bethany, MO 160-Bed Skilled Nursing Facility Date of Notice: May 2004 |
Owner: Harrison County, MO Operator: Crestview Home, Inc. Registered Agent: Edward M. Manning |
Legal Action: Class I Notice of Noncompliance |
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Description: Facility failed to provide adequate supervision and assistance devices to prevent the elopement of two residents (Resident #1 and #2). Resident #1 was found a mile away from the facility by a community member who saw the resident walking in the middle of the road. Resident #2 eloped from the facility on 2/6/04, and was on the side of the highway lying in the snow. A “passerby” notified 9-1-1. |
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Facility: Pine View Manor Stanberry, MO 70- Bed Skilled Nursing Facility Date of Notice: May 2004 |
Owner: Pine View Manor, Inc. Operator: Pine View Manor, Inc. Registered Agent: Karl Frederick |
Legal Action: Class I Notice of Noncompliance |
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Description: Facility failed to notify Resident #1’s physician and family when the resident had an accident and change of condition. Staff failed to increase monitoring and assessment of the resident following the accident even though the resident received multiple skin tears. Staff failed to identify resident’s signs and symptoms of head injury. Resident #1 expired on 4/19/04. |
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Facility: Sunnyview Nursing Home & Apartments Trenton, MO 30-Bed Residential Care Facility Date of Notice: May 2004 |
Owner: Grundy County Nursing Home District Operator: Grundy County Nursing Home District Registered Agent: Not Listed |
Legal Action: Class I Notice of Noncompliance |
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Description: Facility failed to provide adequate supervision to one resident who had a diagnosis of Alzheimer’s Disease, a history of confusion and elopements. The resident eloped on 4/25/04 and staff was unaware the resident was out of the facility. A community member found the resident approximately a mile and a half from the facility and returned the resident to the facility. |
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Facility: Eastview Manor Care Center Trenton, MO 90-Bed Skilled Nursing Facility Date of Notice: May 2004 |
Owner: Eastview Manor, Inc. Operator: Eastview Manor, Inc. Registered Agent: Clyde L. Taff |
Legal Action: Class I Notice of Noncompliance |
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Description: Facility failed to provide adequate supervision and protective oversight for one resident who eloped from the facility undetected. Resident #1 had a history of elopement attempts from the facility. On 3/9/04 the resident attempted to elope and was sent to a local hospital for a psychiatric evaluation. On 4/17/04, resident attempted to elope from the facility. Facility staff failed to develop or implement interventions to address the resident’s elopement attempts. On 5/3/04 at 8:30 p.m., a visitor to the facility found Resident #1 outside the facility at the end of the parking lot in his/her wheelchair. The visitor informed staff of the resident’s location. |
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Facility: Bristol Manor of Maryville Maryville, MO 12-Bed Residential Care Facility Date of Notice: June 2004 |
Owner: Bristol Care, Inc. Operator: Bristol Care, Inc. Registered Agent: David C. Furnell |
Legal Action: Uncorrected Class II Notice of Noncompliance |
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Description: A complaint and licensure inspection was completed on 2/24/04. A revisit was completed on 4/7/04 and 6/3/04 and found the facility was not in substantial compliance. Facility failed to employ an awake night-time attendant for Resident #1 who required the use of a wheelchair to exit the facility in the event of a fire. Facility failed to meet the discharge criteria of a medical reason, welfare of resident or others or non-payment of a bill prior to sending a notice of discharge to Resident #1. Facility failed to promote the exercise of Resident #1’s rights to be free of discrimination based on the resident’s need for use of an assistive device. |
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Facility: Citadel Health Care St. Joseph, MO 100-Bed Skilled Nursing Facility Date of Notice: June 2004 |
Owner: Diamond Health Care Corp. Operator: Citadel Holdings, LLC Registered Agent: Jeffrey K. Phillips |
Legal Action: Uncorrected Class II Notice of Noncompliance |
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Description: Facility failed to: Inform residents of the items and services covered by the daily per diem rate and for items and services for which the resident may be charged; inform residents of their right to manage their own financial affairs; held facility funds on behalf of resident without proper authorization; deposit all residents’ personal funds in excess of $50 in an interest bearing account separate from the facility’s operating accounts, and failed to credit all interest earned on each resident’s funds; follow generally accepted accounting principles when the facility failed to maintain proper internal control; commingled resident funds with facility funds; complete individual financial records for the resident or his or her legal representative on request when deposits and disbursement were not posted accurately or in a timely manner; notify each resident who received Medicaid benefits when the amount of resources reached $200 less than the SSI (Supplemental Security Income) resource limit; ensure that the resident’s funds, and a final accounting of those funds, were conveyed to the individual or probate jurisdiction administering the resident’s estate; provide necessary care and services when they did not contact a physician for treatment orders for a second-degree sunburn for 24 hours and then did not follow physician’s order to treat a resident’s sunburn. |
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Facility: Apple Ridge Care Center Waverly, MO 60-Bed Skilled Nursing Facility Date of Notice: July 2004 |
Owner: Riverview Heights Company Operator: Waverly #1 Inc. Registered Agent: Lonnie G. Hasty |
Legal Action: Class I Notice of Noncompliance |
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Description: Facility continued to care for one resident when the facility could not meet his needs; failed to provide protective oversight and failed to report and investigate abuse and mistreatment. Resident #1 was admitted to the facility January 2004 and since admission had made sexual remarks to the female staff, hit a male resident in the mouth, wandered in and out of other residents’ rooms, was found in a female resident’s room with his shoes off and adjusting his pants, found fondling the breasts of a confused female resident, cut his forearms with a razor and eloped. He had not had a psychological consult since admission until 7/1/04. |
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Facility: Bristol Manor of Brookfield Brookfield, MO 12-Bed Residential Care Facility Date of Notice: September 2004 |
Owner: Bristol Care, Inc. Operator: Bristol Care, Inc. Registered Agent: David C. Furnell |
Legal Action: Class I Notice of Noncompliance |
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Description: Facility failed to provide an awake night attendant as required and did not provide protective oversight for one resident. Resident #1 fell in her room on 9/14/04 at approximately 9:00 p.m. and lay on the floor until approximately 10:00 a.m. on 9/15/04. Resident sustained a hip fracture, wrist fracture, rib fractures, bruising and lacerations. Resident repeatedly called for help but facility staff slept in the manager quarters and did not respond to the resident’s calls for assistance. |
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Facility: Clinton Care & Rehab Center Plattsburg, MO 70-Bed Skilled Nursing Facility Date of Notice: September 2004 |
Owner: Clinton Care & Rehab Center, Inc. Operator: N&R of Plattsburg, LLC Registered Agent: Charlotte Stutts |
Legal Action: Uncorrected Class II Notice of Noncompliance
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Description: Facility failed to correct the following deficiencies: Facility staff did not follow residents’ written plans of care. One resident, who was at risk for dehydration, was not properly monitored for intake and output of fluids. Staff did not provide appropriate care for one resident related to the resident’s lower leg edema. Resident’s legs were not elevated as directed in the plan of care. Facility did not maintain the automatic sprinkler system in working condition. |
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Facility: Ashton Court Care & Rehab Centre Liberty, MO 140-Bed Skilled Nursing Facility Date of Notice: October 2004 |
Owner: Centennial Real Estate Trust Operator: Ashton Court Healthcare, LLC Registered Agent: CSC Lawyers Incorporating Service Company |
Legal Action: Class I Notice of Noncompliance |
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Description: The facility staff failed to provide adequate supervision when one of 16 residents identified at risk for elopement exited the facility on 9/11/04 undetected. Facility staff silenced the audible alarm and returned to normal duties. An unknown couple called the Liberty Police at 7:22 p.m., when they saw the resident fall into a grassy area. At 7:18 p.m., a staff person leaving the facility stopped at a stop sign and noticed the couple and the resident. The resident was assessed with a bruise to his/her left cheek. |
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Facility: Maryville Chateau Maryville, MO 20-Bed Residential Care Facility Date of Notice: October 2004 |
Owner: Nationwide Health Properties, Inc. Operator: Beverly Enterprises-Missouri, Inc. Registered Agent: Prentice-Hall Corporation System |
Legal Action: Class I Notice of Noncompliance |
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Description: The facility failed to provide a safe and effective system of medication distribution for one resident who received another resident’s medication. On 9/12/04 during the breakfast meal facility staff placed Resident #2’s medications on Resident #1’s placemat and vice versa. Resident #1 took Resident #2’s medications. Staff held one of Resident #1’s medications and administered the remaining medications to Resident #1. Within a few minutes Resident #1 complained of not feeling well, had difficulty breathing and could not speak. Staff contacted emergency personnel who transported the resident to the local hospital, however the physician pronounced Resident #1 dead on arrival. |
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Facility: Clinton Care & Rehab Center Plattsburg, MO 70-Bed Skilled Nursing Facility Date of Notice: November 2004 |
Owner: Clinton Care & Rehab Center, Inc. Operator: N&R of Plattsburg, LLC Registered Agent: Charlotte Stutts |
Legal Action: Class I Notice of Noncompliance |
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Description: The facility staff failed to immediately notify the resident’s physician regarding a urine culture showing continued urinary tract infection from 10/14/04 to 10/17/04. Also, the facility failed to recognize and assess for developing sepsis as evidenced by abdominal distention, delirium, profuse diaphoresis, headache and nausea of a quadriplegic resident. |
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Facility: Superior Park Assisted Living Excelsior Springs, MO 66-Bed Residential Care Facility Date of Notice: November 2004 |
Owner: DST, Inc. Operator: DST, Inc. Registered Agent: Thomas A. Walker |
Legal Action: Uncorrected Class II Notice of Noncompliance |
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Description: A complaint investigation was completed at the facility on 8/10/04. A revisit was conducted on 11/4/04. The facility was not in substantial compliance in the following areas: Facility staff failed to maintain a smoke barrier separation in the exit stairwell between the second and third floor. Facility staff failed to maintain the shower room on the first floor in good repair. Also, the staff failed to maintain a fire escape from the second floor. The facility staff failed to maintain furniture and equipment in good repair. Facility staff failed to provide modified diets as ordered by the physician for seven residents. Facility staff failed to post menus including portion sizes for seven residents with physician ordered modified diets. The facility staff failed to maintain exterior driving surfaces grades or graveled driveway to prevent the pooling of water. The facility staff failed to ensure floors in eight resident rooms were clean and in good condition. The facility staff failed to keep the walls and ceilings in 17 resident rooms and two resident use areas clean and in good repair. The facility failed to maintain three resident bathrooms in working order. |
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Facility: Crowder Road Residential Care Trenton, MO 12-Bed Residential Care Facility Date of Notice: November 2004 |
Owner: Lawrence, Willena and Ronnie Operator: Crowder Road Residential Care, LLC Registered Agent: Earnest A. Graypel |
Legal Action: Uncorrected Class II Notice of Noncompliance |
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Description: A complaint investigation was completed on 9/7/04. A revisit was completed on 11/9/04. The facility was not in substantial compliance in the following areas: The facility staff failed to take corrective action to maintain resident’s petty cash fund of no more than fifty ($50) dollars for six residents. Also, the facility failed to place resident funds exceeding fifty dollars into an individual bank account. The facility staff failed to employ a manager who completed the state required Level One Medication Aide (LIMA) course for a Residential Care Facility I. Also, the facility allowed a staff to administer medications that had not completed the LIMA course. The facility owner knowingly allowed residents to keep more than the allowed amount of petty cash funds in the facility, which resulted in money being stolen from three residents. |
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Facility: Woodbine Healthcare & Rehab Centre Gladstone, MO 300-Bed Skilled Nursing Facility Date of Notice: November 2004 |
Owner: Centennial Real Estate Trust Operator: Woodbine Healthcare, LLC Registered Agent: CSC—Lawyers Incorporating Service Company |
Legal Action: Uncorrected Class II Notice of Noncompliance |
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Description: A complaint investigation was completed on 9/3/04 and a survey was completed on 9/27/04. A revisit was completed on 11/10/04. The facility was not in substantial compliance with participation requirements in the following areas: The facility staff failed to clean and maintain resident use furniture, walls, floors, ceilings and equipment. The facility staff failed to use acceptable standards of practice by ensuring to reorder pain medication for one resident and follow physician’s orders for another resident. The facility staff failed to serve food at the proper temperature and cover beverages before transporting. |
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Facility: Royal Care Center, Inc. Excelsior Springs, MO 99-Bed Skilled Nursing Facility Date of Notice: December 2004 |
Owner: Royal Care Center, Inc. Operator: Same Registered Agent: Jesse J. Hwang |
Legal Action: Class I Notice of Noncompliance |
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Description: The facility failed to intervene to protect one resident from verbal and mental abuse after staff reported a certified nurse aide (CNA) repeatedly threatened the resident by telling the resident that if he/she didn’t provide oral sex to his/her roommate the roommate would pull out a gun or knife and use it on him/her. Also, the facility staff failed to investigate and implement their Abuse and Neglect policy and procedure after staff reported verbal and mental abuse of one resident by a CNA. |
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Facility: The Cedargate Poplar Bluff, MO 108-Bed Skilled Nursing Facility
Date of Notice: April 2004 |
Owner: Butler Co. Conv. Ctr., Inc. Operator:.Pro Am, Inc. Registered Agent: Shirley Davenport |
Legal Action: Uncorrected Class II Notice of Noncompliance
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Description: The annual inspection was completed on 2/6/04 with deficiencies cited. A revisit was completed on 4/7/04 with the following uncorrected deficiencies: Facility failed to maintain resident use equipment, doors and walls. Facility failed to follow care plans developed to meet resident needs. Facility failed to provide adequate incontinence care to residents. Facility failed to provide restorative nursing services to prevent a decline in range of motion, to increase range of motion and/or prevent further decrease in range of motion. Facility failed to monitor the use of antipsychotropic medication. Nursing staff failed to wash their hands between resident contacts. |
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Facility: Monticello House Jackson, MO 75-Bed Skilled Nursing Facility Date of Notice: April 2004 |
Owner: Jackson Care Center, LLC Operator: N&R of Monticello, Inc. Registered Agent: Charlotte Stutts |
Legal Action: Uncorrected Class II Notice of Noncompliance |
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Description: The annual survey was completed on 2/6/04 with deficiencies cited. A revisit was completed on 4/5/04. Facility failed to follow physician orders and failed to implement the care plan for three residents. |
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Facility: Riverview Manor Nursing Home Ste. Genevieve, MO 120-Bed Skilled Nursing Facility Date of Notice: May 2004 |
Owner: County of Ste. Genevieve Operator: Riverview Manor Nursing Home, Inc. Registered Agent: Jeanette R. Wood |
Legal Action: Uncorrected Class II Notice of Noncompliance |
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Description: Revisit was completed on 4/29/04 and deficiencies were not corrected. Between 12/16/03 and 4/23/04, 1 resident fell 14 times. As a result of one fall, facility staff sent resident to the emergency room for stitches to close a laceration to the forehead. Facility failed to assess the circumstances of the falls, revise the plan of care and failed to implement interventions to prevent further falls. |
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Facility: River Oaks Care Center Steele, MO 90-Bed Skilled Nursing Facility Date of Notice: October 2004 |
Owner: DCB Real Estate Partnership, LP Operator: Steel #1 Inc. Registered Agent: Lonnie G. Hasty |
Legal Action: Class I and Uncorrected Class II Notice of Noncompliance |
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Description: A survey was completed on 8/4/04. A revisit and complaint investigation was completed on 10/1/04. The facility was issued a Class I violation for failure to provide protective oversight for one resident (Resident #41). Resident #41 had a diagnosis of catatonic schizophrenia characterized by extreme withdrawal. A certified nurse aide locked Resident # in the resident’s bathroom after Resident #41 had been incontinent and refused to take his/her clothes off to be changed. The facility also failed to: Cause a report to be made to DHSS of an allegation of resident abuse. Administer tube feedings according to physician orders. Provide therapeutic diets to residents at nutritional risk, failed to follow recipes when preparing resident meals and failed to store, prepare and distribute foods under sanitary condition to prevent cross-contamination and food-borne illness. Maintain the floor in the kitchen. Maintain an effective pest control system as flies were observed throughout the facility including in the kitchen food preparation/service area and in the resident dining room. |
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Facility: Country Haven Boarding Home Ste. Genevieve, MO 18-Bed Residential Care Facility Date of Notice: December 2004 |
Owner: Chaudhry, LLC Operator: Osman, LLC Registered Agent: Bilkiss Chaudhry |
Legal Action: Uncorrected Class II Notice of Noncompliance |
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Description: At the time of the inspection on 9/21/04 and the revisit on 11/29/04, the facility did not have a licensed nursing home administrator. In addition, the facility failed to maintain doors and flooring in the kitchen in good repair. |
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Facility: Camelot Nursing & Rehabilitation Center Farmington, MO 90-Bed Skilled Nursing Facility Date of Notice: December 2004 |
Owner: BHM Medical Facilities Operator: SCH-Camelot, LLC Registered Agent: Michael Bridges |
Legal Action: REVOCATION OF LICENSURE EFFECTIVE DECEMBER 20, 2004 |
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Description: This decision is based on the following grounds: The operator has demonstrated financial incapacity to operate and conduct the facility in accordance with the provisions of Sections 198.003 to 198.096, RSMo. See Section 198.036.1(4), RSMo Supp. 2003. |
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Facility: Community Springs Healthcare Facility, Eldorado Springs, MO
120-Bed Skilled Nursing Facility
Date of Notice: February 2004 |
Owner: Citizens Memorial Healthcare Foundation Operator: Same Registered Agent: Donald J. Babb |
Legal Action: Class I Notice of Noncompliance
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Description: On 12/27 at 3:00 a.m. facility noted the resident voiced no complaints. At 5:30 a.m. the resident was short of breath, lethargic with an oxygen saturation of 87%. An LPN placed oxygen on the resident but failed to notify the physician. At 6:00 a.m., the resident remained lethargic with an oxygen saturation of 91% and the LPN documented the resident’s nail beds were dusky and altered lung sounds. The LPN increased the resident’s oxygen to 3 liters but did notify the physician. At 6:30 a.m. the resident’s oxygen saturation was still 93%, his/her nail beds remained dusky with no changes in lung sounds. The LPN still did not contact the physician. At 8:00 a.m. the resident’s condition was unchanged with a temperature of 99.3 degrees Fahrenheit and coarse lung sounds. The oncoming RN called the resident’s physician at home without success. At 9:00 a.m., staff contacted the physician at home without success and then called the emergency room but were unable to talk with the physician. At 9:50 a.m., the RN documented the resident’s temperature measured 100.8 degrees Fahrenheit. The RN called the emergency room again and received orders to send the resident to the hospital. The resident expired on 12/27/03 at 6:30 p.m. with a final diagnosis of septic shock. |
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Facility: The Gardens Springfield, MO 148-Bed Residential Care Facility Date of Notice: October 2004 |
Owner: Bethesda Foundation Operator: Bethesda Foundation Registered Agent: C T Corporation Syst. |
Legal Action: Class I Notice of Noncompliance |
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Description: The facility failed to ensure one confused resident remained on the secured unit after an alarmed door sounded. On 10/3/04 at 5:30 p.m., staff reset the alarm and did not look outside or conduct a head count to ensure all residents remained on the unit. At 6:20 p.m. the police were called to a busy intersection approximately 2.5 miles away from the facility and located the resident. The police transported the resident to a local hospital. That evening, an off duty employee recognized a resident walking along the street and called the facility. Staff informed her all residents were accounted for on the unit. The facility did not discover the resident was missing until 8:00 p.m. and filed a missing person report at that time. The hospital contacted the facility and the resident returned to the facility later that night. |
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Facility: Manorcare Health Services Springfield, MO 40-Bed Residential Care Facility Date of Notice: October 2004 |
Owner: Manorcare Health Services, Inc. Operator: Manorcare Health Services, Inc. Registered Agent: CT Corporation Syst. |
Legal Action: Uncorrected Class II Notice of Noncompliance |
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Description: The facility failed to implement a safe and effective system of medication control. A facility LPN placed resident medications in front of residents and walked back to the medication cart and began to prepare other resident medications. The LPN did not stay with residents to ensure residents received the ordered medications. |
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Facility: Page Manor St. Louis, MO
30-Bed Residential Care Facility
Date of Notice: January 2004 |
Owner: Malik Home, LLC Operator: Malik Home, LLC Registered Agent: Saleh Malik |
Legal Action: Uncorrected Class II Notice of Non-compliance |
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Description: Facility failed to provide clear directional exit signs; dispose of ashtray contents appropriately; maintain the building in good repair; maintain all furniture and equipment in good condition and replace broken, torn, damaged and heavily soiled items; clean away dust and debris in resident bedrooms; seal all open gaps in the bathrooms, cleanse surfaces properly and maintain functional toilet stalls and toilet fixtures; maintain sanitary conditions in the kitchen; maintain proper temperatures of the freezers. |
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Facility: McLaran Care Center St. Louis, MO
208-Bed Skilled Nursing Facility
Date of Notice: March 2004 |
Owner: Tenet Health System Hospitals, Inc. Operator: Cathedral Rock Baden, Inc. Registered Agent: Mark A. Shklar |
Legal Action: Uncorrected Class II Notice of Non-compliance |
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Description: Facility failed to provide adequate pressure sore care, maintain medication error rates of less than five percent and serve food to residents at proper temperatures. |
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Facility: The Woodlands of Maryland Heights Maryland Heights, MO
120-Bed Skilled Nursing Facility
Date of Notice: March 2004 |
Owner: Riley-Spence Properties No. 2, LLC Operator: Same Registered Agent: Charles J. Riley |
Legal Action: Uncorrected Class II Notice of Non-compliance |
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Description: A revisit was completed on 3/10/04 and found the facility was not in compliance in the area of Resident Care and Administration. Facility failed to update the plan of care for five residents who required interventions as a result of a fall or injury. Facility staff failed to consistently document the intake and output of three residents receiving nutrition and hydration from a tube feeding. Also, facility failed to develop and add new interventions for four residents who had experienced falls and to document follow-up actions, including neuro checks for one resident as directed in the facility fall policy. |
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Facility: NHC Healthcare-St. Charles St. Charles, MO
120-Bed Skilled Nursing Facility
Date of Notice: March 2004 |
Owner: National Healthcorp Investors, Inc. Operator:
NHC Healthcare/St. Charles, LLC |
Legal Action: Class I Notice of Noncompliance |
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Description: Facility failed to obtain laboratory work and results as ordered by the physician in a timely manner for a resident with a suspected UTI (urinary tract infection). Resident was later hospitalized and expired with final diagnoses of UTI and sepsis. |
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Facility: Springplace St. Louis, MO 254-Bed Skilled Nursing Facility Date of Notice: April 2004 |
Owner: AHM Skld & Assis Liv Ctr of St. Louis Operator: Cathedral Rock of St. Louis, Inc. Registered Agent: Mark A. Shklar |
Legal Action: Class I and Uncorrected Class II Notice of Noncompliance |
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Description: Class I Facility failed to protect residents from physical abuse by another resident. Facility failed to assess and address resident behaviors that presented psychosocial adjustment difficulties and failed to promote the highest level of emotional functioning for residents. Facility failed to supply sufficient staff to provide care and supervision for the residents during the night shift. Uncorrected Class II Facility failed to have PRN (as needed) medications and failed to document administration of such in the medication record. Facility failed to provide treatment for a resident who had an abdominal wound. Facility failed to provide adequate supervision to prevent multiple falls with injuries. |
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Facility: Haven Meadows Care Center Florissant, MO 120-Bed Skilled Nursing Facility Date of Notice: April 2004 |
Owner: Astoria Place, LLC Operator: West Village Manor, LLC Registered Agent: Sharo Shirshekan |
Legal Action: Class I Notice of Non-compliance |
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Description: Facility failed to prevent one resident on the locked geropsychiatric unit from physically and sexually abusing other residents. Facility also failed to investigate and report to documented instances of abuse. |
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Facility: Big Bend Woods Healthcare Center Valley Park, MO 176-Bed Skilled Nursing Facility Date of Notice: April 2004 |
Owner: Monarch Properties, LP Operator: Cedarcroft Health Services, Inc. Registered Agent: National Corporate Research |
Legal Action: Class I and Uncorrected Class II Notice of Noncompliance |
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Description: The revisit and abbreviated survey found the facility was not in substantial compliance with the participation requirements and conditions constitute an immediate jeopardy to the health, safety, and welfare of residents. These conditions involved the facility’s failure to provide the necessary care and services to attain or maintain the highest practicable physical, mental and psychosocial well-being, in accordance with the comprehensive assessment and plan of care (F309). One resident had a decline in condition over 5 days including poor appetite, poor fluid intake and diarrhea. Facility staff did not assess, monitor or provide interventions. The physician was not notified of the decline. The resident was admitted to the hospital on 2/25/04 with diagnoses including severe dehydration. The resident died at the hospital on 3/14/04. Dehydration was a contributing factor to the resident’s death. The facility is also issued an uncorrected notice of non-compliance due to their failure to provide preventative measures and treat residents with pressure sores for six of ten sampled residents with pressure sores. |
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Facility: St. Elizabeth Healthcare & Rehab Ctr. Florissant, MO 160-Bed Skilled Nursing Facility Date of Notice: April 2004 |
Owner: Florissant Property, LLC Operator: St. Elizabeth Healthcare & Rehab Ctr., LLC Registered Agent: Robin Suydam |
Legal Action: Class I Notice of Noncompliance |
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Description: Facility failed to maintain safe hot water temperatures in a range between 105 degrees F and 120 degrees F. Five resident rooms and two shower rooms had hot water temperatures measuring 124.5 degrees F to 135.8 degrees F. |
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Facility: McLaran Care Center St. Louis, MO 208-Bed Skilled Nursing Facility Date of Notice: May 2004 |
Owner: Tenet Healthsystem Hospitals, Inc. Operator: Cathedral Rock of Baden, Inc. Registered Agent: Mark A. Shklar |
Legal Action: Uncorrected Class II Notice of Noncompliance |
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Description: Facility failed to provide care and services to adequately care for residents to promote healing and prevent pressure sore development for three residents. Facility was in noncompliance with pressure sore care during the annual survey/inspection on 1/16/04, during the revisit on 3/4/04 and continues noncompliant during the revisit on 4/20/04. Additionally, the facility’s medication error rate on 1/16/04 was 7/3%, on 3/4/04 it was 6.8% and the current error rate was 13.9%. |
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Facility: Cathedral Gardens Care Center St. Louis, MO 120-Bed Skilled Nursing Facility Date of Notice: May 2004 |
Owner: Oak Forest North, LLC Operator: Cathedral Rock of North St. Louis, Inc. Registered Agent: Mark A. Shklar |
Legal Action: Uncorrected Class II Notice of Noncompliance |
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Description: Facility failed to administer medications as ordered, follow physician orders, ensure electronic door monitoring system was operating properly, obtain weekly weights as ordered, monitor compromised resident’s food and fluid intake, and obtain laboratory work as ordered for 12 of 16 residents. Facility failed to provide infection control care guidelines. |
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Facility: Big Bend Woods Healthcare Center Valley Park, MO 176-Bed Skilled Nursing Facility Date of Notice: May 2004 |
Owner: Monarch Properties, LP Operator: Cedarcroft Health Services, Inc. Registered Agent: National Corporate Research |
Legal Action: Class I Notice of Noncompliance |
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Description: Facility failed to prevent the elopement of one resident from the facility who had previously eloped and had made repeated attempts to elope. Resident eloped at night and was out of the facility approximately two hours before staff noticed him/her missing. Police found the resident 1.5 miles from the facility. |
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Facility: Des Peres Healthcare & Rehab Center Des Peres, MO 111-Bed Skilled Nursing Facility Date of Notice: May 2004 |
Owner: Mo-An of Kansas & MO, LLC Operator: Des Peres Healthcare, LLC Registered Agent: Stephen A. McManus |
Legal Action: Uncorrected Class II Notice of Noncompliance |
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Description: Facility had the following uncorrected deficiencies at the time of the revisit: Facility failed to notify residents when they were within the maximum amounts allowed for Medicaid eligibility. Facility failed to have a complete abuse and neglect policy. Facility failed to treat residents with dignity. Facility failed to maintain hot water at acceptable temperatures (too low). Facility failed to provide medication as ordered, to administer oxygen as ordered and failed to follow physician orders for appropriate diets. Faciltiy failed to provide care and treatment for pressure sores. Facility failed to adequately monitor residents’ behaviors and medication. Facility failed to maintain non-weight bearing status during transfers, maintain good and safe body alignment and failed to provide safety devices to prevent skin tears and bruises. Facility failed to provide thickened liquids and a therapeutic diet. Facility failed to maintain a less than 5% medication error rate. Facility failed to assure foods were palatable and served at the appropriate temperatures. |
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Facility: The Westchester Hours Chesterfield , MO 150-Bed Skilled Nursing Facility Date of Notice: May 2004 |
Owner: Chesterfield Medical Investors, LLC Operator: Consolidated Resources Health Care Fund, I LP Registered Agent: The Corporation Co. |
Legal Action: Uncorrected Class II Notice of Noncompliance |
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Description: Facility failed to assess a resident after a fall that had sustained a hip fracture (Resident #2). Failed to provide adequate hydration as prescribed by the doctor, obtain and report laboratory tests ordered by the doctor, adequately assess the resident when the resident was unable to stay awake during therapy and showed increasing signs of lethargy; resident was admitted to the hospital with urinary tract infection, septic shock and severe dehydration (Resident #4). Failed to record intake and output and provide fluids as ordered by the doctor and obtain laboratory results for residents (Residents #3 and #5). Failed, repeatedly, to obtain lab results used to monitor the dosage of coumadin (a blood thinner) and assess and report the resident’s condition to the physician for one resident (Resident #6) who was admitted to the hospital with coffee ground (blood) emesis secondary to coumadin administration. |
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Facility: The Cedars at the JCA Chesterfield, MO 56-Bed Residential Care Facility Date of Notice: May 2004 |
Owner: Jewish Center for the Aged Operator: Jewish Center for the Aged Registered Agent: Unlisted |
Legal Action: Class I Notice of Noncompliance |
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Description: Based on record review and staff interviews, facility failed to seek medical intervention for one resident who experienced serious changes in his/her condition (Resident #80). Resident died. |
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Facility: St. Elizabeth Healthcare & Rehab Center Florissant, MO 150-Bed Skilled Nursing Facility Date of Notice: June 2004 |
Owner: Florissant Property, LLC Opoerator: St. Elizabeth Healthcare &Rehab Center, LLC Registered Agent: Robin Suydam |
Legal Action: Uncorrected Class II Notice of Noncompliance |
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Description: Facility failed to obtain a wound consultation as ordered by the resident’s physician and failed to notify the physician the consultation was not obtained. Facility failed to complete wound assessments in a timely manner and failed to provide treatments as ordered. The resident was admitted to the hospital with diagnoses including gas gangrene. As a result, a vascular surgeon performed an above the knee amputation of the resident’s left leg. |
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Facility: Blanchette Place Care Center St. Charles, MO 180-Bed Skilled Nursing Facility Date of Notice: July 2004 |
Owner: Claywest House Operator: Cathedral Rock of St. Charles, Inc. Registered Agent: Mark A. Shklar |
Legal Action: Class I Notice of Noncompliance |
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Description: Facility failed to provide appropriate care and services for one resident. Resident had previous elopement attempts and poor decision making abilities. Resident walked out of the facility into a four-lane, heavily traveled access road at approximately 1:00 a.m. A motorist said he/she nearly hit the resident, stopping within only six feet. The motorist said he/she only stopped after seeing the reflection from the resident’s walker as the resident wore a dark robe and slippers. Facility staff were not aware the resident had left the premises. |
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Facility: Sun Valley Manor St. Louis, MO 10-Bed Residential Care Facility Date of Notice: July 2004 |
Owner: Sykes-Aaron, Rosemary Operator: Shontell Davidson Registered Agent: Not Listed |
Legal Action: Uncorrected Class II Notice of Noncompliance |
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Description: Facility failed to follow physician’s orders for one resident and failed to ensure another resident could negotiate a path to safety. Facility failed to provide a smoke detector in the laundry room and failed to prohibit the storage of combustible materials in facility. Facility did not maintain floors, walls and ceilings in good repair. |
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Facility: Mary, Queen and Mother Center Shrewsbury, MO 230-Bed Skilled Nursing Facility Date of Notice: July 2004 |
Owner: Mary Queen and Mother Ass’n. Operator: Mary, Queen and Mother Registered Agent: None |
Legal Action: Uncorrected Class II Notice of Noncompliance |
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Description: Facility failed to correct deficiencies regarding resident care and a malfunctioning call light system. Residents’ physician and nursing orders were not followed and properly transcribed. Facility call light system failed to work properly. |
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Facility: Bernard Care Center St. Louis, MO 141-Bed Skilled Nursing Facility Date of Notice: July 2004 |
Owner: Bernard Associates, LLC Operator: Bernard Care Center, LLC Registered Agent: Richard J. Destefane |
Legal Action: Uncorrected Class II Notice of Noncompliance |
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Description: Facility failed to keep residents’ rooms, furnishings and equipment clean and in good condition. Facility failed to maintain comfortable air temperatures on the 100 unit to meet the needs of the residents. Residents on the 100 unit were exposed to room temperatures and heat indexes ranging from 82 to 91 degrees F. Facility failed to provide treatment as ordered by the physician for one resident with a sore on the great toe that went for several days without treatment. Facility failed to have a medication error rate of 5% or less. Four staff were observed making medication errors which resulted in a medication error rate of 12.5%. |
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Facility: Pacific Care Center, Inc. Pacific, MO 120-Bed Skilled Nursing Facility Date of Notice: July 2004 |
Owner: Pacific Care Center, Inc. Opoerator: Same Registered Agent: Robert E. Schmidt |
Legal Action: Uncorrected Class II Notice of Noncompliance |
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Description: On 6/24/04, an annual survey was conducted at the facility. A revisit was completed on 7/21/04 and found the facility was not in substantial compliance with participation requirements. Review of the medication pass revealed the facility failed to correctly administer medications to three residents resulting in a six percent medication error rate. |
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Facility: McLaran Care Center St. Louis, MO 208-Bed Skilled Nursing Facility Date of Notice: August 2004 |
Owner: Tenet Healthsystem Hospitals, Inc. Operator: Cathedral Rock of Baden, Inc. Registered Agent: Mark A. Shklar |
Legal Action: Class I Notice of Noncompliance |
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Description: Facility did not assess and notify the physician of a resident with a temperature of 104.0 degrees Fahrenheit and thick yellow sputum from the resident’s tracheostomy on 7/5/04 at 9:00 a.m. Resident continued to spike temperatures, the sputum became brown and the resident had rapid and gurgling respirations with a fixed stare. Facility still did not notify the physician. Resident was found unresponsive and without vital signs on 7/6/04 at 10:00 p.m. Facility staff were not aware of the resident’s code status and initiated CPR. Staff stopped CPR upon the discovery of the resident’s no code status. Resident expired at the facility. |
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Facility: Autumn View Gardens at Schuetz Road St. Louis, MO 100-Bed Residential Care Faciltiy Date of Notice: August 2004 |
Owner: Sykes-Aaron, Rosemary Operator: Shontell Davidson Registered Agent: Not Listed |
Legal Action: Class I Notice of Noncompliance |
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Description: Facility failed to provide a safe and effective medication system to enable new nursing staff to identify residents during medication passes and assure the medication is administered to the correct resident for one resident (Resident #1). Facility staff administered the wrong medication to Resident #1. Twenty minutes later, staff found Resident #1 unresponsive. Staff transferred Resident #1 to the local hospital and Resident #1 was placed on a ventilator for three days. |
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Facility: Mary Queen and Mother Center Shrewsbury, MO 230-Bed Skilled Nursing Facility Date of Notice: August 2004 |
Owner: Mary Queen and Mother Ass’n. Operator: Mary Queen and Mother Ass’n. Registered Agent: Ronald A. Mantia |
Legal Action: Uncorrected Class II Notice of Noncompliance |
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Description: Facility failed to implement and transcribe physician orders for four of six sampled residents. |
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Facility: Sabbath Manor St. Louis, MO 64-Bed Residential Care Facility Date of Notice: August 2004 |
Owner: Smith-Miller, Barbara D. Operator: Sabbath Manor, Inc. Registered Agent: Barbara D. Smith |
Legal Action: Uncorrected Class II Notice of Noncompliance |
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Description: Facility failed to correct deficiencies in the areas of Resident Care, Physical Plant and Sanitation for Food Service requirements. The floors in the kitchen and in one bath/shower room were not maintained easily cleanable and in good repair. Facility staff painted the floors. Paint was peeling up creating an unsightly and rough surface. Facility staff failed to administer the correct doses of insulin to two residents. Facility staff failed to store food in a manner to prevent contamination. Foods were not labeled and dated, raw eggs were stored above fresh foods and packages were not sealed. |
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Facility: New Heights Residential Care St. Louis, MO 30-Bed Residential Care Facility Date of Notice: August 2004 |
Owner: Nolting, David L. & Frances J. Operator: Senior Residential LLC Registered Agent: David L. Nolting |
Legal Action: Uncorrected Class II Notice of Noncompliance |
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Description: Facility failed to correct the following deficiencies: One bathroom did not have a bathroom vent fan. Emergency lights were not maintained in working condition. Walls in the basement area were cracked and had holes exposing the wood frame construction. Air conditioning duct work was coated with ice. Insulin was not labeled or dated at the time of opening. The package information directed staff to discard any insulin opened for more than 28-30 days. Additionally, facility staff did not keep the medication refrigerator locked at all times. The refrigerator was accessible to residents and unlocked with no staff present. |
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Facility: The Westchester House Chesterfield, MO 159-Bed Skilled Nursing Facility Date of Notice: September 2004 |
Owner: Chesterfield Medical Investors, LLC Operator: Consolidated Resources Health Care Fund Registered Agent: The Corporation Company |
Legal Action: Uncorrected Class II and new Class III Notice of Noncompliance REVOCATION OF LICENSE |
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Description: On 3/17/04, Section for Long Term Care (SLTC) completed a complaint investigation and found The Westchester House not in compliance with Sections 198.003 to 198.096, RSMo, and standards established thereunder. Revisits and/or inspections were completed by SLTC staff on 5/27/04 and 7/1/04. It was determined facility was not in substantial compliance. A subsequent revisit was completed on 8/25/04 and it was determined facility is not in substantial compliance in the areas of Fire Safety, Physical Plant, Administration and Resident Care, Dietary and Food Service Sanitation as a result of the uncorrected Class II and new Class III violations. SLTC has reviewed the facility’s record, the cited violations and the circumstances and has determined to revoke your license to operate The Westchester House. The license will be null and void on 9/17/04. |
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Facility: Grandview Healthcare Center Washington, MO 102-Bed Skilled Nursing Facility Date of Notice: September 2004 |
Owner: Omega Healthcare Investors, Inc. Operator: Washington N&R, LLC Registered Agent: Stephen W. Dolden |
Legal Action: Uncorrected Class II Notice of Noncompliance |
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Description: Facility failed to correct the following deficiencies: Facility staff failed to provide one resident with an appropriately sized dining room table to allow the resident to feed him/herself. Facility staff did not administer residents’ medications within required timeframes and in accordance with professional standards of administration. One resident’s medications were not given as ordered by the resident’s physician resulting in missed doses. Staff failed to place a lap buddy on a resident’s wheelchair as ordered by the resident’s physician to prevent falls. Resident did not have the lap buddy and received an injury due to a fall from the wheelchair. Facility staff failed to maintain the environment free from offensive urine odors. |
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Facility: Tower Village, Inc. St. Louis, MO 264-Bed Skilled Nursing Facility Date of Notice: October 2004 |
Owner: Tower Village, Inc. Operator: Tower Village, Inc. Registered Agent: Carol A. Weir |
Legal Action: Uncorrected Class II Notice of Noncompliance |
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Description: The facility failed to correct deficiencies in the areas of resident care and resident funds. The facility’s medication administration error rate was 26%. Staff failed to follow residents’ physician orders resulting in missed labs and outdated treatments. The facility failed to properly deposit residents’ personal care money into their accounts and did not refund remaining account balances after residents were discharged. |
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Facility: Provision of Promise St. Louis, MO 20-Bed Residential Care Facility Date of Notice: October 2004 |
Owner: Peterson, Mattie Carolyn Operator: Mattie Carolyn Peterson Registered Agent: None |
Legal Action: Uncorrected Class II Notice of Noncompliance |
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Description: The facility failed to provide a required one-hour separation for the furnace room. |
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Facility: Affton Residential Care Facility Affton, MO 19-Bed Residential Care Facility Date of Notice: October 2004 |
Owner: Sienkiewicz, Inc. Operator: Sienkiewicz, Inc. Registered Agent: Alan Sienkiewicz |
Legal Action: Uncorrected Class II Notice of Noncompliance |
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Description: A revisit was completed on 9/21/04 and the facility was not in compliance due to the following violations in the areas of: Fire safety—fire drills were not conducted and documented as done on each shift. Physical Plant—hot water temperatures were not below 120 degrees. Administrative, Personnel and Resident Care—staff personnel records were not available for review and resident medical did not contain current physician orders. Food Service Sanitation—range hood light bulb was not shielded. Resident’s Funds and Property—there was no written account of resident funds showing receipts and disbursements. Statuary—the Administrator did not complete criminal background checks for all employees and did not check employees against the Employee Disqualification List. New violations were found in the areas: Administrative, Personnel and Resident Care—the Administrator failed to devote sufficient time and attention to facility management and resident care and services. Resident’s Rights—information contained in resident’s medical record is not kept confidential and residents are not informed of items and services covered by the per diem rate or of items resident may be charged; residents not provided with policies regarding resident funds and not allowed access to resident funds during regular business hours; the Administrator did not maintain a written statement showing current balances and transactions of resident funds; residents were not provided with up-to-date accounting of resident funds and balances were not returned to resident within 5 days of the discharge; resident funds were not kept in an interest bearing account; and, the surety bond amount was insufficient. |
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Facility: Beauvais Manor on the Park St. Louis, MO 146-Bed Skilled Nursing Facility Date of Notice: October 2004 |
Owner: Memorial Home, Inc. Operator: Memorial Home, Inc. Registered Agent: Tracy Allison |
Legal Action: Class I Notice of Noncompliance |
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Description: The facility failed to implement measures to address one resident’s aggressive and abusive behaviors. The resident hit several other residents and staff, culminating on 9/26/2004 when the resident tried to choke and hit another resident with a belt. |
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Facility: Heritage Care Center St. Louis, MO 120-Bed Skilled Nursing Facility Date of Notice: October 2004 |
Owner: Heritage Park Assoc. LP Operator: Heritage Care Center of Berkeley, LLC Registered Agent: Richard J. Destefane |
Legal Action: Class I Notice of Noncompliance |
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Description: The facility failed to monitor and maintain hot water temperatures to prevent accident hazards for one resident. On 10/9/04 facility staff assisted a dependent non-verbal resident with a shower. The staff turned the hot water up all the way to hot and did not check the temperature resulting in the resident receiving second and third degree burns over most of his/her body. The facility received a citation during the survey of 9/17/04 for hot water temperatures above 120 degrees Fahrenheit in resident use areas. |
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Facility: Bethesda Southgate St. Louis, MO 180-Bed Skilled Nursing Facility Date of Notice: October 2004 |
Owner: Bethesda Southgate Long Term Care, Inc. Operator: Bethesda Long Term Care, Inc. Registered Agent: John W. Rowe |
Legal Action: Class I Notice of Noncompliance |
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Description: The facility failed to appropriately assess and implement interventions for one resident who staff found with his/her upper body slumped over the side rail. The resident had no signs of life. Autopsy results show the resident died of positional asphyxiation. There was no physician order, assessment or care plan for side rail use. The personal safety alarm, used by facility staff to alert them of the resident’s attempts to get out of bed, was not in use at the time of the incident. |
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Facility: Cathedral Gardens Care Center St. Louis, MO 120-Bed Skilled Nursing Facility Date of Notice: November 2004 |
Owner: Oak Forest North, LLC Operator: Cathedral Rock of North St. Louis, Inc. Registered Agent: Anthony J. Soukenik |
Legal Action: Uncorrected Class II Notice of Noncompliance |
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Description: The facility failed to correct deficiencies in the areas of medication administration and nutrition. The facility had a medication error rate of 9.75% during the revisit inspection. Residents were not accurately assessed and provided interventions to maintain acceptable nutritional status. |
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Facility: Delmar Gardens of Chesterfield Chesterfield, MO 240-Bed Skilled Nursing Facility Date of Notice: November 2004 |
Owner: DGCH, Inc. Operator: Delmar Gardens of Chesterfield, Inc. Registered Agent: Husch Registered Agent, Inc. |
Legal Action: Class I Notice of Noncompliance |
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Description: The facility failed to provide timely, appropriate and continuous cardio pulmonary resuscitation (CPR) for a resident with an order for a full code. The resident expired in the facility. The facility failed to have adequate and readily accessible life saving equipment available for emergencies. |
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Facility: Tower Village, Inc. St. Louis, MO 264-Bed Skilled Nursing Facility Date of Notice: November 2004 |
Owner: Tower Village, Inc. Operator: Tower Village, Inc. Registered Agent: Carol A. Weir |
Legal Action: Uncorrected Class II Notice of Noncompliance |
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Description: The facility failed to correct the following deficiencies: The facility failed to administer medications in accordance with physicians orders. One resident, with a diagnosis of cancer, did not receive his/her OxyContin for 29 hours after the resident’s admission, resulting in missing two doses. The facility failed to maintain a medication error rate of less than 5%. |
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Facility: Bernard Care Center St. Louis, MO 141-Bed Skilled Nursing Facility Date of Notice: December 2004 |
Owner: Bernard Associates, LLC Operator: Same Registered Agent: Richard J. Destefane |
Legal Action: Class I Notice of Noncompliance |
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Description: The facility failed to adequately monitor a 24-year old resident with a history of seizures. The resident had two seizures on the day shift, then two more seizures during the night shift. Staff did not assess or monitor the resident, did not notify the physician of any of those seizures and the resident expired at the facility. |
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Facility: The Lighthouse of Festus, Inc. Festus, MO 25-Bed Residential Care Facility Date of Notice: December 2004 |
Owner: Grey Street, Inc. Operator: The Lighthouse of Festus, Inc. Registered Agent: David P. Linderer |
Legal Action: Class I Notice of Noncompliance |
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Description: The facility failed to provide a complete fire alarm system in accordance with the applicable edition of NFPA 72, by ensuring fire actuating devices activated the fire alarm when triggered. On 11/17/04 three of four pull stations did not operate when tested. In addition, one smoke detector in the main corridor located in the area of the kitchen and television room did not function when a burning/smoldering paper was placed under it. |
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Facility: Spanish Lake Nursing Center Florissant, MO 120-Bed Skilled Nursing Facility Date of Notice: December 2004 |
Owner: Three Amigos of Spanish Lake, Inc. Operator: Spanish Lake Nursing & Rehab Center, Inc. Registered Agent: David L. Kamler |
Legal Action: Class I Notice of Noncompliance |
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Description: The facility failed to: Assure each resident was free from physical abuse; prevent further potential abuse while an investigation was in progress; immediately report the results of the investigation to the state survey agency. On 11/6/04, a CNA saw an LPN strike an uncooperative confused resident at approximately 6:00 a.m. The resident had a swollen lip and repeated to several staff, “She hit me.” The LPN continued to work as a charge nurse providing care to residents, including resident #1, until 1:00 p.m. when he/she left for the day. Administrative staff were aware of the allegation and allowed the LPN to remain in the facility. Residents reported that prior to this date, they were intimidated by this LPN. The allegation was not reported to the Elder Abuse Hotline until 11/19/04. |
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