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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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