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Missouri Long-term Care Facility

Notices of Non-Compliance

2004

2004 Nursing Home Non-Compliance by Region:

1. Southwest Region
2. Southeast Region
3. Kansas City Region
4. Northwest Region
5. Northeast Region
6. Central Region
7. St. Louis Region

NORTHEAST REGION

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

 

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.

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

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 residentís whereabouts during periods of substance abuse, failed to notify the residentís physician about the residentís substance abuse and failed to notify the physician regarding the residentís 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.

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

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.

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

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.

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

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 physicianís orders.

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

Description: Facility assessed Resident #1 with completely limited sensory perception including unresponsive to painful stimuli. Resident #1ís diagnoses included quadriplegia. On 3/3/04, resident complained of back pain and a facility LPN applied a hydrocollator pack to the residentís lower back without a physicianís order for the treatment. Facility transferred resident to the hospital and the hospital staff discovered deep partial thickness burns on the residentís 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.

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

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.

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

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.

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

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 physicianís 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.

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

Description: Facility failed to administer medications according to physicianís orders which resulted in a medication error rate of 16%.

Facility: Westview Nursing Center

Center, MO
60-Bed Skilled Nursing Facility

Date of Notice: September 2004

Owner: BNH Enterprises, Inc.

Operator: BKY, Inc.

Registered Agent: Brandon York

Legal Action: Uncorrected Class II Notice of Noncompliance

Description: Facility failed to hold one residentís medication as ordered and failed to correctly transcribe a medication order to the residentís 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.

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

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 residentís 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.

Facility: Luther Manor Retirement & Nursing Ctr.

Hannibal, MO

60-Bed Skilled Nursing Facility

Date of Notice: October 2004

Owner: Luther Manor Assín.

Operator: Luther Manor Assín.

Registered Agent: Sharon K. Moore

Legal Action: Class I Notice of Noncompliance

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 residentís 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 residentís condition. At 8:30 a.m., the staff documented the residentís 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.

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

Description: The facility failed to follow physicianís 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 residentís 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.

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

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.

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

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 residentís physician regarding the residentís 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.

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

Description: On 7/4/04, the facility failed to notify one residentís physician regarding the residentís lethargy and a change in his/her urine. The facility failed to notify the residentís physician regarding abnormal urinalysis results in a timely manner and failed to report the residentís condition decline including decreased intake. On 7/9/04, the staff documented the resident was unresponsive to verbal stimuli but failed to notify the residentís 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 residentís 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.

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

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.

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

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.