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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

ST. LOUIS REGION

 

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

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.

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

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.

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

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.

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
Registered Agent: National Registered Agents, Inc.

Legal Action:

Class I Notice of Noncompliance

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.

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

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.

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

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.

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

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.

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

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.

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

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%.

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

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.

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

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.

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

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.

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

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.

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

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.

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

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.

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

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.

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

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.

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

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.

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

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%.

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

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.

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

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.

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

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.

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

Description: Facility failed to implement and transcribe physician orders for four of six sampled residents.

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

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.

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

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.

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

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.

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

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.

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

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.

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

Description: The facility failed to provide a required one-hour separation for the furnace room.

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

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.

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

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.

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

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.

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

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.

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

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.

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

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.

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

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%.

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

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.

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

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.

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

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.