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Notices of Non-Compliance

2004

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

SOUTHWEST REGION

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

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.

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

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.

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

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.