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Missouri Long-term Care
Facility Notices of Non-Compliance 2005 |
2005 Nursing Home Non-Compliance by Region: 1. Southwest Region |
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Facility: Jefferson Lodge Fulton, MO 94-Bed Residential Care Facility
Date of Notice: January 2005 |
Owner: Rescare of Missouri, Inc. Operator: Rescare of Missouri, Inc.
Registered Agent: Eric F. Fink, Jr.
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Legal Action: Uncorrected Class II Notice of Noncompliance
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Description: A complaint investigation was completed on 12/13/04. The facility was not in substantial compliance with participation requirements. A revisit was completed on 1/14/05. The facility staff failed to prohibit the use of a portable space heater in the facility. |
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Facility: Bristol Manor of Boonville Boonville, MO 12-Bed Residential Care Facility
Date of Notice: January 2005 |
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:. An annual licensure inspection was completed on 11/16/04. The facility was not in substantial compliance with participation requirements. A revisit was conducted on 1/13/05. The facility staff failed to ensure that one resident is capable of negotiating a path to safety. The resident requires hearing assistive devices to hear, however the devices are taken out at night. The facility staff failed to provide the resident with a tactile or visual device to alert the resident of the fire alarm sounding. |
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Facility: Columbia Healthcare Center Columbia, MO 97-Bed Skilled Nursing Facility Date of Notice: January 2005 |
Owner: NHI of Columbia, LLC Operator: NHI of Columbia, LLC Registered Agent: National Registered Agents |
Legal Action: Class I Notice of Noncompliance |
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Description: The facility failed to maintain safe water temperatures below 120 degrees Fahrenheit in all resident accessible areas. Hot water temperatures of 160 degrees Fahrenheit were found in two resident rooms located on the Special Care Unit. |
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Facility: Jefferson City Nursing & Rehab Center Jefferson City, MO 120-Bed Skilled Nursing Facility
Date of Notice: February 2005 |
Owner: Not Listed Operator: Jefferson City Nursing & Rehab Ctr., LLC Registered Agent: Lawyers Incorporating Service Company |
Legal Action: Uncorrected Class II Notice of Noncompliance |
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Description: An annual survey was completed on 12/10/04. A revisit was completed on 2/4/05. The facility was not in substantial compliance with participation requirements in the following areas: Facility staff failed to ensure pharmacy recommendations and physician orders were followed for one resident. Facility staff failed to serve the correct portion sizes for mechanically altered diets according to the menu. Facility staff failed to maintain dietary equipment in a clean and sanitary manner. Also, facility staff failed to maintain hot foods at the minimum acceptable temperature for hot holding (140 degrees F) and to reheat potentially hazardous foods to a temperature of 165 degrees F for 15 seconds. |
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Facility: Moniteau Care Center California, MO 60-Bed Skilled Nursing Facility Date of Notice: March 2005 |
Owner: Latham Care Center, Inc. Operator: N&R of California, Inc. Registered Agent: Charlotte Stutts |
Legal Action: Class I Notice of Non-compliance |
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Description: The facility failed to clarify an order and failed to correctly transcribe the medication order. The resident received methotrexate (a medication which can be used to treat cancer and severe rheumatoid arthritis) 7.5 mg daily from 1/23/05 through 2/10/05 instead of 7.5 mg every Sunday. The resident was admitted to the hospital with diagnoses which included methotrexate toxicity, thrombocytopenia (a decreased number of platelets in a person’s blood that can be caused by certain drugs) and leukopenia (a decreased number of white blood cells). |
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Facility: Rest Haven Convalescent & Retirement Home Sedalia, MO 86-Bed Intermediate Care Facility Date of Notice: March 2005 |
Owner: John T. Finley, Inc. Operator: John T. Finley, Inc. Registered Agent: John C. Finley |
Legal Action: Class I and Uncorrected Class II Notice of Noncompliance |
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Description: A survey was completed on 1/13/05. A revisit and complaint investigation was completed on 3/3/05. The facility failed to correct Class II violations cited on 1/13/05 and was cited for a new Class I violation at the 3/3/05 visit. UNCORRECTED VIOLATIONS - The facility failed to: follow a physician orders for one resident who required fluid restrictions; to maintain resident assessments (minimum data set) completed within the previous 15 months in the resident’s active record for three residents; prepare and serve pureed diets according to the recipe and menu for two residents; accurately weigh individual portions of meats for seven residents who required specific calorie diets, according to the recipe and serve the appropriate amount of foods as directed by the menu. CLASS I VIOLATION – The facility failed to provide adequate supervision to prevent accidents for one confused visually impaired resident who had a history of wandering and leaving the building. On 3/1/05 resident #1 left the building without staff knowledge. An off duty facility staff found the resident walking down the middle of the road with a van driving behind the resident. The staff parked his/her car and returned the resident to the facility. |
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Facility: Riverview Nursing Center Mokane, MO 60-Bed Skilled Nursing Facility Date of Notice: March 2005 |
Owner: DCB Real Estate Partnership, LP Operator: Mokane #1, Inc. Registered Agent: Lonnie G. Hasty |
Legal Action: Class I Notice of Non-compliance |
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Description: The facility staff failed to ensure each resident receives adequate supervision and assistance devices to prevent accidents for one resident. Resident #1 had diagnoses which included dysphagia with choking episodes. The resident had a history of coughing at meals and continuing to put food in his/her mouth. The care plan directed staff to serve a mechanically soft diet, monitor responses to diet and request order for any modifications needed. During the meal on 1/18/05, one staff person, assisting dependent residents with eating, remained in the dining room. A resident alerted the staff that Resident #1 was choking. Staff attempted the Heimlich maneuver without success. The resident’s cause of death was due to food aspiration. |
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Facility: Oak Tree Villas, Inc. Jefferson City, MO 39-Bed Intermediate Care Facility Date of Notice: April 2005 |
Owner: Oak Tree Villas, Inc. Operator: Oak Tree Villas, Inc. Registered Agent: Don Chapman |
Legal Action: Class I Notice of Noncompliance |
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Description: The facility failed to prevent one confused resident from leaving the facility without staff knowledge. A passerby found the resident walking along the side of the roadway. The resident was disoriented and could not find his/her way back to the facility. The passerby contacted the police who returned the resident back to the facility. |
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Facility: West Woods Care Center Bourbon, MO 12-Bed Residential Care Facility Date of Notice: April 2005 |
Owner: Converse, Richard and Audrey Operator: Converse Residential Adult Home Registered Agent: Husch Registered Agent, Inc. |
Legal Action: Uncorrected Class II Notice of Noncompliance |
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Description: The facility failed to adhere to state laws on guardianship. State law prohibits an administrator, owner, operator, manager or employee of a facility licensed by the Department of Mental Health or the Department of Social Services from serving as a resident’s guardian. The owner/manager of the facility serves as guardian for one resident. |
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Facility: Sunset Health Care Center Union, MO 120-Bed Skilled Nursing Facility Date of Notice: May 2005 |
Owner: Sunset Retirement Homes, Inc. Operator: Sunset Retirement Homes, Inc. Registered Agent: Dennis G. Menos |
Legal Action: Class I Notice of Noncompliance |
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Description: The facility staff failed to provide appropriate supervision to prevent one resident from sexually abusing another confused resident. The resident had a history of sexually inappropriate behavior toward other residents and staff. Facility staff failed to develop and implement interventions to prevent further abuse. |
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Facility: Jefferson Lodge Fulton, MO 94-Bed Residential Care Facility Date of Notice: June 2005 |
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 complaint investigation was completed on 4/5/05. A revisit was completed on 5/27/05. The facility was not in substantial compliance with participation requirements in the following areas: Facility staff failed to ensure the proper disposal of cigarettes and ashes. Facility staff failed to ensure multi-outlet adapters and multiple extension cords were not used in the facility. Facility staff failed to maintain furniture in good condition. Facility staff failed to store cleaning materials in locked cabinets inaccessible to residents. Facility staff failed to clean and maintain the carpeting. Facility staff failed to ensure outside openings were protected against the entrance of insects. |
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Facility: Good Shepherd Care Center Versailles, MO 124-Bed Skilled Nursing Facility Date of Notice: June 2005 |
Owner: Good Shepherd N.H. District #1 Operator: Good Shepherd N.H. District #1 Registered Agent: Not Listed |
Legal Action: Class I Notice of Noncompliance |
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Description: Facility staff failed to ensure two residents received adequate supervision during bathing, to prevent near drowning for one resident. Facility staff gave a shower and a bath to two residents at the same time in the shower/bath room. Resident #1 was in the tub and unable to support self while sitting. The resident slid under straps used to position resident while the staff person finished showering and dressing the other resident. Staff discovered Resident #1 under the water. Resident #1 was admitted to the hospital with a diagnosis of near drowning and pneumonia. The report indicated the resident aspirated a significant amount of water and was in serious condition. |
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Facility: Westphalia Retirement Center Westphalia, MO 59-Bed Skilled Nursing Facility Date of Notice: June 2005 |
Owner: Retirement Center Management, Inc. Operator: Retirement Center Management, Inc. Registered Agent: Don Chapman, Jr. |
Legal Action: Class I Notice of Noncompliance |
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Description: The facility failed to provide adequate supervision to prevent one confused resident with a history of elopements from leaving the facility without staff knowledge. The unattended resident left the facility and crossed highway 63, a heavily traveled 60-mile per hour highway. The resident was found one mile from the facility. A driver passing by saw the resident and stopped to check on the resident. The resident was taken back to the facility. Facility staff were unaware the resident was missing. |
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Facility: Frene Valley Health Center Hermann, MO 100-Bed Skilled Nursing Facility Date of Notice: June 2005 |
Owner: Frene Valley Corp. Operator: Lloyd Health Care Management Systems, Inc. Registered Agent: Husch Registered Agent, Inc. |
Legal Action: Class I Notice of Noncompliance |
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Description: The facility failed to assess and monitor one resident’s needs for side rails and failed to provide adequate supervision and assistive devices to prevent accidents. Facility staff failed to prevent one confused resident from suffocating, when the resident attempted to get out of bed unassisted and became wedged between the mattress and the bedrail. Also, facility staff failed to develop and implement a plan of care associated with the use of side rails for one resident. |
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Facility: Jefferson Lodge Fulton, MO 94-Bed Residential Care Facility Date of Notice: July 2005 |
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: The facility failed to maintain toxic chemicals in an area which was not accessible to residents. |
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Facility: Autumn Meadows Linn, MO 132-Bed Skilled Nursing Facility Date of Notice: July 2005 |
Owner: Piedra, Enrique & Cherribeth Operator: Autumn Meadows, LLC Registered Agent: John H. Simmons |
Legal Action: Uncorrected Class II Notice of Noncompliance |
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Description: A survey was completed on 5/19/05. A revisit and complaint investigation was completed on 7/15/05. The facility is not in substantial compliance with participation requirements. The facility staff failed to provide adequate supervision and assistance devices to prevent accidents and injuries for one resident with a history of falls. Resident #1 fell on 5/28/05, the resident fell on 6/30/05 sustaining an abrasion to hip and a hematoma to the right elbow and the resident fell again on 7/11/05 sustaining a hematoma and laceration to back of head that required sutures and a left hip fracture. |
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Facility: Heisinger Lutheran Home Jefferson City, MO 111-Bed Residential Care Facility Date of Notice: July 2005 |
Owner: Cole Co. Lutheran Home Assn. Operator: Cole Co. Lutheran Home Assn. Registered Agent: Not Listed |
Legal Action: Class I Notice of Noncompliance |
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Description: The facility staff failed to provide adequate supervision of three cognitively impaired residents residing in the Special Care Unit who left the building on 6/20/05, without staff knowledge. Resident #1 fell in the employee parking lot and received a fractured shoulder, cerebral contusion (bruise of the brain), small traumatic subarachnoid hemorrhage (bleeding of the membrane covering the brain) and facial lacerations requiring sutures. The alarm on the door leading to the employee parking lot had either been disabled by staff or malfunctioned. |
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Facility: Warrenton Manor Warrenton, MO 120-Bed Skilled Nursing Facility Date of Notice: August 2005 |
Owner: Fellowship Nursing Home, Inc. Operator: Warrenton Manor, LLC Registered Agent: Sharo Shirshekan |
Legal Action: Uncorrected Class II Notice of Noncompliance |
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Description: A complaint investigation was completed on 7/1/05. A revisit was completed on 7/29/05. The facility was not in substantial compliance with participation requirements. Facility staff failed: To maintain in a clean manner resident’s equipment and one resident room floor. Follow one resident’s physician orders for dressing changes. Ensure one dependent resident was repositioned every two hours. Ensure pest control traps were functional to reduce pest problems in the facility. |
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Facility: Lakeview Health Care and Rehab Center Boonville, MO 60-Bed Skilled Nursing Facility Date of Notice: August 2005 |
Owner: Bedell, Don C. & Pamela/Barrow, Chel Operator: Boonville #1, Inc. Registered Agent: Lonnie G. Hasty |
Legal Action: Class I Notice of Noncompliance |
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Description: The facility staff failed to have a system in place to ensure hot water from fixtures accessible to residents is consistently maintained at or below 120 degrees Fahrenheit. Facility staff found the hot water temperatures in two showers rooms measured 135 degrees F on 6/25/05 and 7/23/05, but failed to analyze the cause and implement a solution to bring the temperature to 120 degrees or below. Also, facility staff failed to provide adequate supervision for one confused resident with a history of elopement attempts from leaving the facility without staff knowledge. The resident who had a history of removing the code alert bracelet exited the facility and walked three-fourths of a mile before a community person contacted the facility staff to alert them the resident was not at the facility. |
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Facility: South Hampton Place Columbia, MO 100-Bed Skilled Nursing Facility Date of Notice: September 2005 |
Owner: Corporate Care Center, Inc. Operator: N&R of South Hampton, LLC Registered Agent: Charlotte Stutts |
Legal Action: Class I Notice of Noncompliance |
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Description: A survey was completed on 8/25/05. The facility was not in substantial compliance with participation requirements. The facility staff failed to have a system in place to assure hot water from fixtures accessible to residents is maintained at or below a 120 degrees Fahrenheit. The hot water at the hand sink in the dining room measured 150 degrees F, the south shower room hand sink measured 127 degrees and the shower stall measured 125 degrees F. The coffee machine, which is accessible to residents, measured 162 degrees F. The facility failed to maintain professional standards of practice for medication administration and gastrostomy feeding administration for four residents. Facility staff failed to ensure doors protected corridor openings and ensure resident room doors latch to prevent the passage of smoke. |
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Facility: Westphalia Retirement Center Westphalia, MO 59-Bed Skilled Nursing Facility Date of Notice: September 2005 |
Owner: Retirement Center Management, Inc. Operator: Retirement Center Management, Inc. Registered Agent: Don Chapman, Jr. |
Legal Action: Class I Notice of Noncompliance |
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Description: The facility staff failed to provide adequate oversight and supervision for one confused resident with a history of elopements from leaving the facility. On 9/3/05 a community member found Resident #1 walking along the shoulder of the road on Highway 63. The facility staff were unaware the resident had left the facility until a community member returned the resident to the facility and the resident’s wander guard alarm sounded upon entering the building. A resident reported to facility staff that Resident #1 gained access to the RCF portion of the building with the assistance of a RCF resident. Facility staff had given the code to the keypad that allows access from the RCF to the SNF to alert residents in the RCF. |
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Facility: Good Shepherd Care Center Versailles, MO 124-Bed Skilled Nursing Facility Date of Notice: October 2005 |
Owner: Good Shepherd N.H. District #1 Operator: Good Shepherd N.H. Dist. #1 Registered Agent: Not Listed |
Legal Action: Class I Notice of Noncompliance |
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Description: An annual survey was completed on 9/23/05. The facility was not in substantial compliance with participation requirements. Facility staff failed to provide a system to ensure the hot water from fixtures accessible to residents was consistently maintained at or below 120 degrees Fahrenheit (F). Facility staff was aware for at least ten days that the water temperatures had been high due to the valves being clogged. Facility staff had been unable to correct the problem and had not contacted an outside contractor to repair the valves or put any measures in place to prevent possible burns from hot water. The hot water temperatures measured 130 degrees F. |
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Facility: Warrenton Manor Warrenton, MO 120-Bed Skilled Nursing Facility Date of Notice: November 2005 |
Owner: Fellowship Nursing Home, Inc. Operator: Warrenton Manor, LLC Registered Agent: Sharo Shirshekan |
Legal Action: Uncorrected Class II Notice of Noncompliance |
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Description: A survey was completed on 9/15/05. A revisit was completed on 11/08/2005. The facility was not in substantial compliance with participation requirements. Facility staff failed to properly handle soiled linens to prevent the spread of infection for two residents. |
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Facility: The Bluffs Columbia, MO 132-Bed Skilled Nursing Facility Date of Notice: November 2005 |
Owner: Boone County Commission Operator: Boone Co. Senior Citizen Services Corp. Registered Agent: Cindy Forbis |
Legal Action: Uncorrected Class II Notice of Noncompliance |
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Description: A survey was completed on 9/29/05. The facility was not in substantial compliance with participation requirements. A revisit was completed on 11/14/05. The facility failed to notify a physician of recommendations made by the dietician for one resident with identified weight loss and two Stage II pressure ulcers; and failed to administer medicated eye drops to one resident with proper technique. |
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Facility: Sylvia G. Thompson Residence Center Sedalia, MO 90-Bed Skilled Nursing Facility Date of Notice: December 2005 |
Owner: Sylvia G. Thompson Charitable Trust Operator: Sylvia G. Thompson Residence Center, Inc. Registered Agent: Adam B. Fischer |
Legal Action: Class I Notice of Noncompliance |
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Description: The facility failed to provide adequate supervision and oversight for one confused resident with a history of wandering. The resident wore a wander alert device due to his/her elopement risk. On 11/18/05 around 1:00 p.m. the resident left the facility and walked to a shopping center and local bank. Two staff members heard the door alarm but did not go to the door to see if a resident had exited the building. The resident walked to a bank located approximately a half-mile away from the facility. A bank teller telephoned the facility and the administrator brought the resident back to the facility. The street in front of the shopping center and bank is a four-lane street with a speed limit of 35 miles per hour. |
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Facility: Tipton Manor, Inc. Tipton, MO 66-Bed Skilled Nursing Facility Date of Notice: December 2005 |
Owner: City of Tipton, Missouri Operator: N&R of Tipton, LLC Registered Agent: Terry, C. Allen |
Legal Action: Uncorrected Class II Notice of Noncompliance |
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Description: A complaint investigation was completed on 9/30/05. The facility was not in substantial compliance with participation requirements. A revisit and survey was completed on 11/30/05. The facility failed to ensure sufficient nursing staff were available to provide monitoring and supervision for 15 dependent and confused residents that live on the Special Care Unit. |
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Facility: Plaza Manor Kansas City, MO 154-Bed Skilled Nursing Facility
Date of Notice: March 2005 |
Owner: Plaza Manor Associates Operator: Plaza Manor, Inc. Registered Agent: Joseph Tutera |
Legal Action: Uncorrected Class II Notice of Noncompliance |
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Description: A revisit was completed on 3/14/05. The facility had violations in the areas of Administration and Resident Care Requirements, Dietary Requirements, General Sanitation, Food Service Sanitation and Resident Rights. The facility census was 134 residents. The facility had a medication error rate of 17%. The facility failed to document and notify the physician of one resident’s refusal of insulin injections to treat diabetes. Assess the diabetic needs of another resident and obtain physician’s orders for blood glucose monitoring and insulin. Provide assistance with grooming. Provide treatment for residents with pressure ulcers; provide treatment to prevent urinary tract infections. Practice acceptable hand washing techniques during wound treatment and medication administration. Provide care and treatment to prevent abrasions to the legs of a diabetic resident. Properly transcribe physician orders. Keep feeding tube insertion sites into resident’s abdomen clean. Assess residents’ complaints of pain. The facility failed to follow up on the Registered Dietician’s nutritional recommendations to promote acceptable parameters of nutritional status. Honor one resident’s request to get out of bed and to have enough transfer devices to get another resident out of bed. Follow recipes when preparing pureed foods. Store food free from spoilage. Keep the kitchen area clean. Properly store kitchen utensils in a sanitary manner. |
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Facility: Rosewood Health Center Independence, MO
300-Bed Skilled Nursing Facility
Date of Notice: March 2005 |
Owner: Reorganized Church of Jesus Christ Operator: The Groves Registered Agent: Karen E. Minton |
Legal Action: Uncorrected Class II Notice of Noncompliance |
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Description: A revisit and complaint investigation was completed on 3/14/05. The facility census was 276 residents. The facility failed to ensure one resident received personal attention and nursing care in accordance with his/her condition. The facility administered the resident the wrong medication for three days. The resident had a decline in condition and was sent to the hospital for evaluation. |
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Facility: The Greens at Creekside Kansas City, MO 180-Bed Skilled Nursing Facility
Date of Notice: April 2005 |
Owner: Healthcare Property Investors, Inc. Operator: Fayjay, Inc. Registered Agent: Stephanie G. Hazelton |
Legal Action: Uncorrected Class II Notice of Non-Compliance
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Description: At the revisit completed on 3/29/05, the facility was found to have the following violations in the areas of Administration and Resident Care and Food Services Sanitation. The facility staff failed to clarify physician orders for thickened liquids, provide appropriate incontinence care to prevent urinary tract infections for residents with foley catheters, use appropriate transfer techniques for residents dependent upon staff for transfers and to wash their hands as indicated by accepted professional infection control practice. The facility also failed to serve residents milk at the proper temperature, failed to ensure sanitary conditions were maintained for food storage, preparation and service to prevent potential food borne illnesses. |
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Facility: Regency Care Center of Independence, L.C. Independence, MO 120-Bed Skilled Nursing Facility Date of Notice: May 2005 |
Owner: Regency Properties, L.C. Operator: Regency Care of Independence, L.C. Registered Agent: Will A. Markel |
Legal Action: Uncorrected Class II Notice of Noncompliance |
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Description: At the time of the revisit on 5/2/05, the facility had an uncorrected deficiency in the area of Administration and Resident Care. The facility failed to follow their policies for the use of urinary catheters, for clarifying orders with the physician and for infection control for one resident who had a foley catheter at the time of admission to the facility on 3/23/05. There was no documentation in the medical record by the physician or by nursing staff to show a diagnosis or clinical justification for the continued use of the catheter. By 4/6/05, the resident showed signs of a urinary tract infection caused by methicillin resistant staphylococcus aureus (MRSA) bacteria. On 4/26/05, laboratory tests revealed the resident had a yeast infection and a urinary tract infection. The physician did not specify the justification for the continued use of the catheter until 4/27/05 and did not discontinue use of the catheter until 5/5/05. |
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Facility: White Ridge Health Center Lee’s Summit, MO 60-Bed Skilled Nursing Facility Date of Notice: May 2005 |
Owner: Missouri Regency Assoc., Ltd. Operator: Deaconess Long Term Care of Missouri, Inc. Registered Agent: The Corporation Company |
Legal Action: Class I Notice of Non-compliance |
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Description: Facility staff failed to provide adequate supervision and monitoring to one confused resident with a history of elopement attempts from leaving the facility without staff knowledge. On 5/3/05 at 12:30 p.m. staff found Resident #1 going out a dining room door and returned the resident to the dining room. At 2:52 p.m. that same afternoon, the facility received a call from a local hospital social worker informing the facility the resident was at the emergency room. The resident was in the emergency room for treatment of bruises to the left eye and a laceration to the upper lip that required stitches. The staff did not know the resident had left the facility until notified by the hospital social worker. |
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Facility: Jolet Home Kansas City, MO 17-Bed Residential Care Facility Date of Notice: June 2005 |
Owner Thompson Lee Operator: Jolet II Inc. Registered Agent: Lawrence Thompson |
Legal Action: Uncorrected Class II Notice of Noncompliance |
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Description: The facility failed to correct the following deficiencies: Food was stored improperly. Opened, perishable food items in the refrigerator/freezer were not covered, labeled and dated. Food items stored in the refrigerator were past their “use by” dates. The facility’s food storage area stored food in dented cans and additional items, which were past their “use by” dates. Facility staff failed to correctly screen new and potential employees as required. The criminal background checks and Employee Disqualification List checks were not done on all new hires within the required time frames. |
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Facility: Hidden Lake Care Center Raytown, MO 102-Bed Skilled Nursing Facility Date of Notice: June 2005 |
Owner: Stratford Health Care Group, Inc. Operator: Stratford Health Care Group, Inc. Registered Agent: Kenneth R. Blom |
Legal Action: Uncorrected Class II Notice of Noncompliance |
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Description: The facility failed to provide supervision and failed to revise the resident’s plan of care after falling. The facility had identified one resident at risk for falls. The resident fell two times and the facility did not revise the plan of care to address the resident’s falls. The resident fell a third time that resulted in facial fractures and injuries. The resident was transferred to the emergency room and underwent surgery to correct the facial injuries. |
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Facility: Cedar Valley Health Center Raytown, MO 154-Bed Skilled Nursing Facility Date of Notice: July 2005 |
Owner: Missouri Regency Assoc., Ltd. Operator: Deaconess Long Term Care of MO, Inc. Registered: The Corporation Company |
Legal Action: Uncorrected Class II Notice of Noncompliance |
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Description: An inspection and survey was completed on 5/27/05. A revisit was completed on 7/18/05. The facility had the following uncorrected deficiencies: Nursing staff failed to correctly transcribe physician orders for pressure sore treatment that resulted in staff providing the incorrect pressure sore treatment to one resident. The facility failed to provide sufficient staff to supervise and prevent one confused resident from eating food from other resident’s meal trays. The facility failed to protect stored food from contamination, keep non-food contact surfaces of cookware and the kitchen floor clean and free of excess debris and failed to preserve the cleanliness of food contact surfaces used for baking and preparing meals for all residents. |
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Facility: Rosewood Health Center Independence, MO 300-Bed Skilled Nursing Facility Date of Notice: August 2005 |
Owner: Reorg Church of Jesus Christ Operator: The Groves Registered Agent: Karen E. Minton |
Legal Action: Uncorrected Class II Notice of Noncompliance |
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Description: The facility had the following deficiencies at the revisit completed 8/1/05: Staff failed to notify the physician of a change of condition for one resident. Staff failed to identify medical symptoms, assess behavioral symptoms and implement interventions to address those behaviors before using a physical restraint for one resident. Staff failed to follow physician’s orders and administer the correct oxygen flow rate for one resident. Staff failed to appropriately remove a pain-relieving patch from one resident’s arm and caused a skin tear. Staff applied a narcotic pain-relieving patch to the wrong resident. Staff failed to apply a medicated patch to lower blood pressure to resident who had high blood pressure. Staff failed to provide incontinence care to residents and use acceptable hand washing techniques to prevent contamination and potential urinary tract infections. Staff failed to use gait belts when transferring one resident to prevent the potential for accidents. The facility had a medication error rate of 7.5%. The facility failed to provide appropriate pharmaceutical services to assure the correct accounting and control of controller narcotic pain medications. The facility failed to maintain all smoke barriers free from penetrations to resist the passage of smoke. The facility failed to ensure smoke dampers automatically closed with activation of the fire alarm system. |
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Facility: Jolet Home Kansas City, MO 17-Bed Residential Care Facility Date of Notice: August 2005 |
Owner: Thompson Lee Operator: Jolet II, Inc. Registered Agent: Lawrence Thompason |
Legal Action: Uncorrected Class II Notice of Noncompliance |
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Description: The facility failed to correct the following deficiencies: Fire drills were not conducted quarterly on each shift. The fire alarm system was not tested monthly. The facility food storage area contained multiple dented and/or outdated canned foods. The facility staff failed to provide documentation to verify new employees were checked for criminal backgrounds and against the employee disqualification list. |
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Facility: White Oak Manor Kansas City, MO 64118 150-Bed Skilled Nursing Facility Date of Notice: August 2005 |
Owner: White Oak Manor Place, LLC Operator: White Oak Manor, LLC Registered Agent: Sharo Shirshekan |
Legal Action: Uncorrected Class II Notice of Noncompliance |
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Description: A survey was completed on 5/12/05. A revisit was completed on 8/9/05. The facility was not in substantial compliance with participation requirements. The facility failed to follow and implement the abuse/neglect policies by not suspending one employee during an investigation of alleged inappropriate conduct during care. The facility failed to maintain a dignified environment for residents and provide residents a method to report concerns of staff’s disruptive behavior without fear of repercussions. Residents witnessed staff being disciplined by the Director of Nurses yelling at staff in the halls. Also, the facility failed to assure facility staff discarded multi dose bottles of insulin medication 30 days after being opened. |
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Facility: IHS of KC at Alpine North Kansas City, MO 186-Bed Skilled Nursing Facility Date of Notice: September 2005 |
Owner: Meditrust Company, LLC Operator: IHS of Cliff Manor, Inc. Registered Agent: National Corporate Research |
Legal Action: Uncorrected Class II Notice of Noncompliance |
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Description: A survey was completed on 6/29/05. A revisit was completed on 8/24/05. The facility was not in substantial compliance with participation requirements in the following areas: The facility staff failed to follow accepted standards of practice for administering medications and fluids per gastronomy tube for two residents. Also, the facility staff failed to assure physician orders were followed for one resident. The facility failed to assure staff maintained a medication error rate of less than 5%. Out of 41 opportunities staff made 5 errors in administration of medications resulting in an error rate of 12%. Facility staff failed to maintain acceptable infection control practices when providing resident care. |
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Facility: Timberlake Care Center Kansas City, MO 150-Bed Skilled Nursing Facility Date of Notice: September 2005 |
Owner: Mission Lake Convalescent Center, Inc. Operator: Mission Lake Convalescent Center, Inc. Registered Agent: Robert W. Walters |
Legal Action: Uncorrected Class II Notice of Noncompliance |
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Description: Survey was completed on 6/27/05 and the facility was not in substantial compliance. The revisit was completed on 8/15/05 and the facility still was not in substantial compliance due to uncorrected violations in the areas of: Administration and Resident Care Requirements – the facility had a medication error rate of 9.3%; failed to follow physician orders, failed to provide care and treatment to promote the healing of pressure sores, prevent development of new pressure sores and to identify newly developed pressure sores; failed to provide appropriate catheter care; and failed to wash their hands according to accepted standards of practice. Dietary Services – staff failed to serve food in an appropriate consistency to meet resident needs. General Sanitation – staff failed to keep the facility free of odors. |
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Facility: Valley View Assisted Living Lees Summit, MO 155-Bed Residential Care Facility Date of Notice: September 2005 |
Owner: John Knox Village Operator: John Knox Village Registered Agent: SHB Registered Agent, Inc. |
Legal Action: Class I Notice of Noncompliance |
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Description: The facility failed to maintain a complete and operable fire alarm system in the area of the building containing the kitchen, chapel and resident dining room. When tested on three separate times on 9/1/05, the hold-open devices on the fire doors adjacent to the facility dining room did not release when the fire alarm was activated. The facility census was 109 residents. |
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Facility: Rosewood Health Center Independence, MO 300-Bed Skilled Nursing Facility Date of Notice: October 20, 2005 |
Owner: Reorg Church of Jesus Christ Operator: The Groves Registered Agent: Karen E. Minton |
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 complete a thorough investigation of verbal abuse against one resident by a staff person. The facility failed to follow policy and procedures to ensure accurate documentation of controlled drug records. |
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Facility: Carondelet Manor Kansas City, MO 162-Bed Skilled Nursing Facility Date of Notice: November 2005 |
Owner: Carondelet Health Operator: Carondelet LTC Fac, Inc. Registered Agent: Not Listed |
Legal Action: Class I Notice of Noncompliance |
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Description: The facility failed to permit one resident (Resident #1) to stay in the facility after the resident had surgery at a local hospital. The facility also failed to give Resident #1 a thirty-day discharge notice. Resident #1 was discharged from the hospital on 10/25/05 and surgery to correct a cardiac problem. On 10/25/05, the facility issued Resident #1 a discharge letter to be effective that day. Facility staff failed to document in Resident #1’s discharge letter adequate reasons for the discharge, failed to assist Resident #1 in finding appropriate placement after the discharge, failed to obtain a physician’s order for the discharge and failed to allow Resident #1 to stay in the facility after Resident #1 filed an appeal. |
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Facility: Golden Acres Independence, MO 16-Bed Residential Care Facility Date of Notice: December 2005 |
Owner: Jones Jill Operator: Teresa Henry Registered Agent: Not Listed |
Legal Action: Uncorrected Class II Notice of Noncompliance |
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Description: A licensure inspection was completed on 9/20/05. A revisit was completed on 12/2/05. The facility failed to complete the following: Maintain an annual inspection and certification of the fire alarm system. To perform and document monthly tests of the smoke detectors. Maintain an inspection of the electrical wiring every two years. Maintain employee personnel record in the facility. Follow physician orders and obtain laboratory tests. Ensure medications are safely stored in a secured location behind one locked door or cabinet. Develop and implement a safe and effective medication system. Maintain a written account of resident funds. Maintain a surety bond when holding resident funds. Perform and maintain documentation of employees criminal background checks. Perform and maintain documentation of employee disqualification checks for all employees. |
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Facility: Chariton Park Health Care Center Salisbury, MO 95-Bed Skilled Nursing Facility
Date of Notice: March 2005 |
Owner: Salisbury Associates, LLC Operator: Chariton Park Health Care Center, LLC Registered Agent: Richard J. Destefane |
Legal Action: Uncorrected Class II Notice of Noncompliance
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Description: The facility failed to ensure a safe and effective medication system with a medication error rate of 5% or less. The facility staff committed six errors out of 26 opportunities. The facility staff failed to wash their hands after their gloves were soiled with body substances. The facility also failed to maintain the sprinkler system in reliable operating condition in accordance with NFPA 13. |
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Facility: ABC Health Center Harrisonville, MO 60-Bed Skilled Nursing Facility
Date of Notice: April 2005 |
Owner: Missouri Regency Associates Ltd. Operator: Deaconess Long Term Care of Missouri, Inc. Registered Agent: The Corporation Company |
Legal Action: Class I Notice of Noncompliance |
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Description: The facility failed to provide appropriate assessment and intervention for residents after facility staff witnessed sexual incidents, failed to notify the physician and legal guardians to develop appropriate interventions for residents who engage in sexual acts and failed to develop appropriate care plans based on the input of the physician and legal guardians for two residents (Resident #1 and Resident #3). Facility staff witnessed at least three sexual incidents, dating back to 12/3/04, between Resident #1 and Resident #3. Facility staff identified these incidents as consensual even though both residents have legal guardians. Facility staff did not contact either legal guardian or develop and implement care plans to address these behaviors. |
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Facility: Moberly Nursing & Rehab Moberly, MO
120-Bed Skilled Nursing Facility
Date of Notice: April 2005 |
Owner : Ravenwood Manor Homes, Inc. Operator: N & R of Moberly, Inc. Registered Agent: Charlotte Stutts |
Legal Action: Uncorrected Class II Notice of Non-compliance |
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Description: The facility failed to maintain a medication administration rate less than 5%. During medication administration observation, facility staff committed eight errors out of 47 opportunities. |
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Facility: Elsberry Missouri Health Care Center Elsberry, MO 60-Bed Intermediate Care Facility
Date of Notice: April 2005 |
Owner: Lincoln County Missouri Operator: Elsberry Missouri Health Care Center, Inc. Registered Agent: Robert Davis |
Legal Action: Uncorrected Class II Notice of Noncompliance |
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Description: The facility failed to maintain a medication error rate less than 5%. Staff committed five medication errors out of 50 medication pass observations which resulted in a 10% error rate. Staff failed to administer 28 doses of medication for eight residents as ordered by the physician. |
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Facility: Crosspointe Residential Care Facility, Inc. Edina, MO 47-Bed Residential Care Facility
Date of Notice: April 2005 |
Owner: Crosspointe RCF, Inc. Operator: Crosspointe Residential Care Facility, Inc. Registered Agent: Tony D. Small |
Legal Action: Uncorrected Class II Notice of Non-compliance |
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Description: The facility failed to prevent storage of combustible materials in the attic and in the furnace room. |
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Facility: Kozy Korner II Hannibal, MO 10-Bed Residential Care Facility
Date of Notice: April 2005 |
Owner: Hannibal Health Resources, Inc. Operator: Hannibal Health Resources, Inc. Registered Agent: Kathryn L. Miller |
Legal Action: Uncorrected Class II Notice of Noncompliance |
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Description: The facility had the following uncorrected deficiencies at the time of the revisit: The electromagnetic device attached to the fire separation door between the first and second floors failed to function properly. The facility failed to maintain floors, walls, doors and bathrooms clean and in good repair. |
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Facility: Country View Nursing Facility, Inc. Bowling Green, MO 60-Bed Skilled Nursing Facility Date of Notice: April 2005 |
Owner: CCC Country View, LLC Operator: Country View Nursing Facility, Inc. Registered Agent: James J. Giardina |
Legal Action: Uncorrected Class II Notice of Noncompliance |
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Description: The facility failed to provide adequate supervision to prevent accidents during transfer of one resident with the mechanical lift and to prevent two residents from physical altercations. |
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Facility: Maple Lawn Residential Care Facility Fayette, MO Date of Notice: April 2005 |
Owner: Health Care Consultants of Mid-Missouri, Inc. Operator: Health Care Consultants of Mid-Missouri, Inc. Registered Agent: Sue Braun |
Legal Action: Uncorrected Class II Notice of Noncompliance |
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Description: The facility failed to ensure three of seven resident room wall coverings were made of a material of the appropriate flame spread rating. The facility installed wood paneling in resident rooms to cover holes in the walls. The paneling was purchased at a commodity salvage business and facility staff had no knowledge of the fire rating. In addition, the facility failed to provide appropriate electrical outlets for residents’ electrical appliances. Many outlets had surge protectors plugged into a duplex outlet. The surge protectors had as many as six appliances plugged into them. |
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Facility: HRT Lodge, Inc. Hannibal, MO 24-Bed Residential Care Facility Date of Notice: May 2005 |
Owner: Ghattas, Sandra Operator: HRT Lodge, Inc. Registered Agent: Jeffrey R. Curl |
Legal Action: Uncorrected Class II Notice of Noncompliance |
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Description: The facility failed to ensure water temperatures at plumbing fixtures remained between 105 degrees Fahrenheit and 120 degrees Fahrenheit. |
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Facility: Lincoln County Nursing & Rehab Troy, MO 90-Bed Skilled Nursing Facility Date of Notice: July 2005 |
Owner: Troy Healthcare Center, Inc. Operator: N&R of Lincoln County, Inc. Registered Agent: Charlotte Stutts |
Legal Action: Uncorrected Class II Notice of Noncompliance |
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Description: Facility staff failed to follow physician’s orders and failed to monitor input and output for two residents with catheters and one resident on fluid restriction. Facility staff failed to transcribe medication orders correctly and failed to obtain resident medications in a timely manner. Facility staff also failed to provide necessary services to maintain personal hygiene for five incontinent residents. |
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Facility: Kozy Korner I Hannibal, MO 12-Bed Residential Care Facility Date of Notice: August 2005 |
Owner: Hannibal Health Resources, Inc. Operator: Hannibal Health Resources, Inc. Registered Agent: Kathryn L. Miller |
Legal Action: Class I Notice of Noncompliance |
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Description: The facility failed to provide adequate supervision for one resident with a history of suicide attempts and a recent admission to the hospital for depression with suicidal ideations. The resident was admitted to the facility on 7/18/05 and the facility did not implement a system to monitor the resident’s behavior. On 7/23/05, facility staff could not locate the resident and began to search the premises. The resident was located in his/her closet after he/she hung himself/herself with a strap. The resident was not revived and expired on 7/23/05. |
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Facility: Clark County Nursing Home Kahoka, MO 118-Bed Skilled Nursing Facility Date of Notice: September 2005 |
Owner: Clark Co. Nursing Home Dist. Operator: Clark Co. Nursing Home Dist. Registered Agent: None |
Legal Action: Uncorrected Class II Notice of Noncompliance |
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Description: The facility failed to administer the correct doses of insulin as ordered for four residents and failed to administer the correct type of insulin for one resident. |
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Facility: Fountain Court Care Center Hannibal, MO 38-Bed Skilled Nursing Facility Date of Notice: October 2005 |
Owner: Rupp Phyllis King Operator: Leah, Inc. Registered Agent: Phyllis King Rupp |
Legal Action: Uncorrected Class II Notice of Noncompliance |
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Description: The facility failed to provide effective personal hygiene for two residents. The facility failed to implement measures to prevent the development of pressure ulcers and failed to assess and treat pressure ulcers. Facility staff failed to transfer one resident in a safe manner and failed to ensure a medication error rate of less than 5%. |
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Facility: Fountain Court Care Center Hannibal, MO 38-Bed Skilled Nursing Facility Date of Notice: November 2005 |
Owner: Rupp Phyllis King Operator: Leah, Inc. Registered Agent: Phyllis King Rupp |
Legal Action: Uncorrected Class II Notice of Noncompliance |
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Description: The facility failed to provide appropriate care to one resident’s surgical wound site. The facility failed to implement measures to prevent the development of pressure ulcers and failed to assess and treat pressure ulcers. Facility staff failed to ensure a medication error rate of less than 5%. The facility failed to develop a detailed written evacuation plan. |
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Facility: Moore-Pike Nursing Home Bowling Green, MO 64-Bed Skilled Nursing Facility Date of Notice: December 2005 |
Owner: Pike County Court Operator: Moore-Pike Nursing Home, Inc. Registered Agent: Martha E. Moore |
Legal Action: Uncorrected Class II Notice of Noncompliance |
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Description: The facility failed to complete the installation of fire rated corridor doors to the dining room and failed to ensure two resident room doors closed without impediment. |
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Facility: Apple Ridge Care Center Waverly, MO 60-Bed Skilled Nursing Facility Date of Notice: December 2005 |
Owner: Riverview Heights Co. Operator: Waverly #1 Inc. Registered Agent: Lonnie G. Hasty |
Legal Action: Class I Notice of Noncompliance |
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Description: The facility failed to ensure a resident having pressure sores receives the necessary treatment and services to promote healing, prevent infection and prevent new sores from developing. The facility failed to provide pressure relief for one resident’s bed or chair, failed to develop a plan of care and failed to thoroughly assess one resident’s pressure ulcers, which resulted in numerous stage II, II and IV pressure ulcers. |
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Facility: Chariton Park Health Care Center Salisbury, MO 95-Bed Skilled Nursing Facility Date of Notice: December 2005 |
Owner: Salisbury Associates, LLC Operator: Chariton Park Health Care Center, LLC Registered Agent: Richard J. Destefane |
Legal Action: Class I Notice of Noncompliance |
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Description: The facility failed to notify the authority having jurisdiction and failed to implement an approved fire watch when the required automatic sprinkler system was out of service for more than 4 hours in a 24-hour period and there were parties left unprotected by the shutdown. The facility staff discovered a break in the sprinkler system piping which required the system to be shut down. The facility staff failed to notify the authority having jurisdiction and failed to implement an approved fire watch while the required sprinkler system was non-functional. This left multiple sections of the building with no fire suppression or fire notification in the even of a fire and affected all residents. The facility census was 82. |
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Facility: Chariton Park Health Care Center Salisbury, MO 11-Bed Residential Care Facility Date of Notice: December 2005 |
Owner: Salisbury Associates, LLC Operator: Chariton Park Health Care Center, LLC Registered Agent: Richard J. Destefane |
Legal Action: Class I Notice of Noncompliance |
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Description: The facility failed to notify the authority having jurisdiction and failure to implement an approved fire watch when the required automatic sprinkler system was out of service for more than 4 hours in a 24-hour period and there were parties left unprotected by the shutdown. The facility staff discovered a break in the sprinkler system piping which required the system to be shut down. The facility staff failed to notify the authority having jurisdiction and failed to implement an approved fire watch while the required sprinkler system was non-functional. This left multiple sections of the building with no fire suppression or fire notification in the event of a fire and affected all residents. The facility census was 6. |
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Facility: Maple Lawn Nursing Home Palmyra, MO 140-Bed Skilled Nursing Facility Date of Notice: December 2005 |
Owner: Marion Co. Nursing Home Dist. Operator: Marion Co. Nursing Home Dist. Registered Agent: Not Listed |
Legal Action: Uncorrected Class II Notice of Noncompliance |
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Description: The facility failed to maintain the dignity of one resident during care; failed to reposition three dependent residents; failed to provide appropriate hygiene care to six incontinent residents; failed to apply torso supports on two residents properly to prevent potential accidents; and failed to have a medication error rate of five percent or less. |
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Facility: Saxton Care Chateau St. Joseph, MO 69-Bed Intermediate Care Facility
Date of Notice: January 2005 |
Owner: Saxton’s TLC, Inc. Operator: Chateau Place, Inc. Registered Agent: Glen Muir |
Legal Action: Uncorrected Class II Notice of Noncompliance
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Description: The facility failed to acknowledge one resident’s numerous requests to be taken to the toilet and lay down. The facility failed to provide proper perineal and urinary catheter care. The facility failed to assure staff used appropriate transfer techniques to reduce the possibility of injury and failed to assure staff washed hands when appropriate to maintain infection control standards osf practice. |
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Facility: Troy Manor LLC Troy, MO 120-Bed Skilled Nursing Facility Date of Notice: February 2005 |
Owner: HML of Troy, Inc. Operator: Troy Manor, LLC Registered Agent: Sharo Shirshekan |
Legal Action: Class I Notice of Noncompliance |
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Description: The administration of the facility failed to maintain the required sprinkler and smoke detection systems in working order during a major remodeling. The administration made no alternate fire safety provisions while the systems were not functional. The local fire department was not notified, Department of Health and Senior Services was not notified and no facility staff were performing fire watches of the facility. Exit doors and exit hallways were obstructed and/or locked with unapproved or malfunctioning devices. |
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Facility: Troy Manor LLC Troy, MO 120-Bed Skilled Nursing Facility Date of Notice: March 2005 |
Owner: HML of Troy, Inc. Operator: Troy Manor, LLC Registered Agent: Sharo Shirshekan |
Legal Action: Uncorrected Class I Notice of Noncompliance |
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Description: The facility failed to provide a homelike environment and failed to complete construction projects. The facility also failed to follow physician’s orders, ensure safe transfers, and maintain a medication error rate less than 5%. The facility also failed to ensure corridor doors had proper hardware and latching devices and failed to maintain the automatic sprinkler system. |
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Facility: Crowder Residential Care Trenton, MO 12-Bed Residential Care Facility Date of Notice: March 2005 |
Owner: Lawrence, Willena & Ronnie Operator: Crowder Road Residential Care, LLC Registered Agent: Ernest A. Graypel |
Legal Action: Uncorrected Class II Notice of Noncompliance |
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Description: A revisit was completed at the facility on 11/9/04. A revisit was completed on 2/23/05. The facility was not in substantial compliance with participation requirements. The facility staff failed to: treat all residents in the facility with dignity and respect by repeatedly yelling and cursing at or around the residents; provide all residents access to their funds during regular business hours and maintain residents’ funds in excess of $50.00 in a bank or savings and loan association; maintain residents’ petty cash fund of no more than fifty dollars; provide all residents receipts to and disbursements from, the personal funds of for personal care items staff purchased using the residents’ personal funds; provide four residents with receipts for pharmaceutical purchases made by the operator and paid for from the residents’ personal funds; provide individual financial records through quarterly statements and upon request to the resident or his/her legal representative; return to one resident an up-to-date accounting of the resident’s personal funds and the balance of the funds within five (5) days of the resident’s discharge. |
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Facility: Quail Run Health Care Center Cameron, MO 64-Bed Skilled Nursing Facility Date of Notice: March 2005 |
Owner: DCB Real Estate Partnership, LP Operator: Cameron #1, Inc. Registered Agent: Lonnie G. Hasty |
Legal Action: Uncorrected Class II Notice of Noncompliance |
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Description: An abbreviated survey was completed on 11/23/04 and an annual survey was completed on 12/14/04. A revisit was completed on 2/15/05. The facility was not in substantial compliance with participation requirements in the following areas: Facility staff failed to assess one resident before applying a restraint and failed to monitor the resident for the appropriateness of the restraint. Facility staff failed to follow physician orders for one resident. Staff failed to obtain prn (as necessary) oxygen saturation measurements prior to administering oxygen therapy. Facility staff failed to assess for the appropriateness and safety of a restraint applied to one resident and failed to transfer a second resident in a safe manner. |
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Facility: Superior Park Assisted Living Excelsior Springs, MO 66-Bed Residential Care Facility Date of Notice: March 2005 |
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 on 8/10/04. Revisits were completed on 11/04/04, 1/05/05 and 3/18/05. The facility was not in substantial compliance with participation requirements for fire safety standards and physical plant. The facility staff failed to assure all new or replacement curtains were certified or sprayed to be flame resistant. Also, the facility staff failed to maintain resident rooms and use area floors, wall and ceilings were clean and in good repair. |
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Facility: Pearl’s Residential Care Princeton, MO 26-Bed Residential Care Facility Date of Notice: March 2005 |
Owner: Bagley, Roger C. & Judy Heck Operator: Pearl’s Residential Care, LLC Registered Agent: Roger C. Bagley |
Legal Action: Uncorrected Class II Notice of Noncompliance |
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Description: A survey was completed at the facility on 12/3/04. A revisit was completed on 3/3/05. The facility was not in compliance with participation requirements. The facility failed to: Ensure no section of the building presented a fire hazard. Facility staff failed to maintain the commercial clothes dryer free of a buildup of lint. Ensure two residents were able to negotiate a normal path to safety in case of an emergency. Obtain a physician’s order for a 45-day recuperation for one resident. Transfer three residents who required a higher level of care to meet their physical and mental needs. |
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Facility: Pleasant Valley Manor Care Center Liberty, MO 102-Bed Skilled Nursing Facility Date of Notice: April 2005 |
Owner: Witt & Juckette Construction Co. of IA Operator: Pleasant Valley Manor, Inc. Registered Agent: Hal Juckette |
Legal Action: Uncorrected Class II Notice of Noncompliance |
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Description: A survey was completed on 2/17/05. The facility was not in substantial compliance with participation requirements. A revisit was completed on 4/12/05. The facility was not in compliance in the area of Fire Safety. The facility failed to provide sprinkler coverage to an outside covered porch, which extended more than 48 inches. |
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Facility: Crestview Home, Inc. Bethany, MO 160-Bed Skilled Nursing Facility Date of Notice: April 2005 |
Owner: Harrison County Missouri Operator: Crestview Home, Inc. Registered Agent: Edward M. Manring |
Legal Action: Class I Notice of Noncompliance
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Description: A complaint investigation was completed on 1/25/05. The facility was not in substantial compliance with participation requirements. A survey was completed on 3/18/05. The facility staff failed to immediately inform the resident, consult with the resident’s physician; and if known, notify the resident’s legal representative or an interested family member when there is a significant change and a need to alter treatment (F157). Also, the facility failed 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). The facility staff failed to notify one resident’s physician on 1/1/05, when the resident’s bone protruded through the skin and did not initiate treatment until 1/6/05. The wound became infected and the resident required amputation of the leg. In addition, the facility was cited for substandard quality of care violations. |
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Facility: Pine View Manor, Inc. Stanberry, MO 70-Bed Skilled Nursing Facility Date of Notice: April 2005 |
Owner: Pine View Manor, Inc. Operator: Pine View Manor, Inc. Registered Agent: Karl Frederick |
Legal Action: Uncorrected Class II Notice of Noncompliance |
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Description: A survey was completed on 2/8/05. The facility was not in substantial compliance with participation requirements. A revisit was completed on 4/7/05. The facility staff failed to: Ensure a safe system of self-administration of medication for one resident. Assure physician orders had been obtained for two medications kept at one resident’s bedside. Assure a medication error rate of less than 5%. There were three medication error with 40 opportunities for error, resulting in an error rate of 7%. |
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Facility: Superior Park Assisted Living Excelsior Springs, MO 66-Bed Residential Care Facility Date of Notice: May 2005 |
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 on 8/10/04. Revisits were completed on 11/4/04, 1/5/05 and 3/18/05. The facility was not in substantial compliance in the following areas: Fire Safety – Facility staff failed to ensure all new window blinds were either constructed of metal or certified as flame resistant in three resident rooms. Physical Plant Requirements – Facility staff failed to maintain floors, walls and ceilings in resident rooms and common use areas including common shower and toilet rooms and the smoking lounge in good repair. |
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Facility: Sunnyview Nursing Home & Apartments Trenton, MO 154-Bed Skilled Nursing Facility Date of Notice: June 2005 |
Owner: Grundy County Nursing Home District Operator: Grundy County Nursing Home District Registered Agent: Not Listed |
Legal Action: Uncorrected Class II Notice of Noncompliance |
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Description: A survey was completed on 4/18/05. A revisit was completed on 6/15/05. The facility was not in substantial compliance with participation requirements. The facility failed to notify the responsible party and physician when one resident fell and sustained a large hematoma on the forehead. |
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Facility: Crowder Road Residential Care Trenton, MO 12-Bed Residential Care Facility Date of Notice: June 2005 |
Owner: Lawrence, Willena & Ronnie Operator: Crowder Road Residential Care, LLC Registered Agent: Ernest A. Graypel |
Legal Action: Uncorrected Class II Notice of Noncompliance |
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Description: An inspection was completed on 9/7/04. Revisits were completed on 11/9/04, 2/23/05 and 6/5/05. The facility is not in substantial compliance in the following areas: Facility staff failed to assure residents received appropriate care to meet their needs. Facility staff failed to arrive at the facility to pass scheduled medications for seven residents. A qualified facility staff was not on duty to pass medications at the scheduled time (7 P.M.) and residents had to wait for over an hour and twenty minutes for facility staff to arrive to pass the evening medications. Facility staff failed to provide adequate oversight for one resident by allowing unsupervised contact with children, which violated the resident’s living conditions of the resident’s living arrangements. |
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Facility: Worth County Convalescent Center Grant City, MO 60-Bed Skilled Nursing Facility Date of Notice: June 2005 |
Owner: Worth County Nursing Home District Operator: Worth County Nursing Home District Registered Agent: Not Listed |
Legal Action: Uncorrected Class II Notice of Noncompliance |
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Description: Based upon a revisit completed 6/2/05, the facility is not in compliance in the following areas: The facility failed to provide services that meet professional standards by not anchoring urinary catheters. The facility failed to modify treatment for one residents’ pressure sore to promote healing of the sore. The facility failed to perform catheter care and perineal care for residents with indwelling catheters. The facility failed to assess and provide appropriate interventions to address one resident’s aggressive behaviors. The facility failed to ensure the residents’ environment remained free of accident hazards and failed to assess the appropriateness of bedrail use for one resident. |
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Facility: Crestview Home, Inc. Bethany, MO 160-Bed Skilled Nursing Facility Date of Notice: June 2005 |
Owner: Harrison County Missouri Operator: Crestview Home, Inc. Registered Agent: Edward M. Manring |
Legal Action: Uncorrected Class II Notice of Noncompliance |
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Description: A revisit was completed on 5/19/05 and the facility was not in compliance due to the following violations: Facility staff failed to notify the family in a timely manner after one resident experienced a fall. Facility staff failed to inform resident about the facility’s grievance policy. Facility staff failed to place call light cords within reach of residents and failed to answer call lights in a timely manner. Facility staff failed to provide social service interventions needed to evaluate residents for proper placement in the facility. Facility staff failed to maintain windows in good repair. Facility staff failed to follow up on recommendations made by the Registered Dietitian and to follow facility policy regarding gastrostomy tube placement. Facility staff failed to safely use power strips in resident rooms and the dining area. The facility failed to provide sufficient staff to meet the need of the residents. Facility staff failed to offer each resident a nourishing bedtime snack. Facility staff failed to label sample packages of medication with resident’s names and to ensure the sample packages provided appropriate information concerning the medication. The facility failed to maintain corridor doors resistive to the passage of smoke. Corridor doors were equipped with drop-down/wedge devices; doors gapped with light visible from the other side; doors did not latch; doors were equipped with roller-latches. The facility failed to maintain smoke barrier doors to resist the passage of smoke. The facility failed to maintain one-hour fire separation between hazardous areas and corridors. The facility failed to maintain access to all exits. The facility failed to maintain a complete sprinkler system. The facility failed to maintain an electronically supervised detection system to monitor low temperatures for all areas where water-filled sprinkler pipes provided coverage. The facility failed to provide self-closing metal containers for residents and staff to empty cigarette ashes into. |
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Facility: Lexington Care Center Lexington, MO 160-Bed Skilled Nursing Facility Date of Notice: August 2005 |
Owner: Santa Fe Mo Associates, LLC Operator: Santa Fe Skilled Care, LLC Registered Agent: Robert H. Epstein |
Legal Action: Uncorrected Class II Notice of Noncompliance |
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Description: A survey was completed on 6/22/05. A revisit was completed on 8/11/05. The facility was not in substantial compliance with participation requirements. The facility failed to provide appropriate nursing care and monitoring for three residents with restraints. The facility staff failed to assess residents needs for side rails and belt restraints and develop care plan interventions to direct staff providing resident care. Also, facility staff failed to update two residents’ plan of care with interventions to address problems identified on comprehensive assessments. |
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Facility: Pearls II Eden for Elders Princeton, MO 60-Bed Skilled Nursing Facility Date of Notice: August 2005 |
Owner: Not Listed Operator: Pearl’s II Eden for Elders, LLC Registered Agent: Rober C. Bagley |
Legal Action: Class I Notice of Noncompliance |
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Description: The facility staff failed to provide adequate supervision to prevent two residents from leaving the facility without staff knowledge. Resident #1 left the facility on 6/4/05 and was found by a neighbor who contacted the facility. Facility staff failed to assess, develop and implement interventions to address the resident’s elopement risk. On 7/27/05 Resident #1 left the facility without staff knowledge and a passerby alerted staff the resident was at the top of the hill. Resident #2 left the facility without staff knowledge on 4/26/05 and made it a fourth of a mile on Highway 65. Facility staff failed to document the incident, assess the resident and develop interventions to address the resident’s elopement risk. |
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Facility: Carriage Square Health Care Center St. Joseph, MO 130-Bed Skilled Nursing Facility Date of Notice: August 2005 |
Owner: Carriage Square Health Care Center, Inc. Operator: Carriage Square Health Care Center, Inc. Registered Agent: William Burford |
Legal Action: Uncorrected Class II Notice of Noncompliance |
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Description: A survey was completed on 6/1/05. A revisit was completed on 7/21/05. The facility was not in substantial compliance with participation requirements. Facility staff failed to ensure services provided by the facility met professional standards of quality. Facility staff failed to date multi dose vials of insulin with the date opened for three residents and staff continued to use one bottle of insulin four months after the manufacturer’s expiration date. |
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Facility: Livingston Manor Care Center Chillicothe, MO 94-Bed Skilled Nursing Facility Date of Notice: September 2005 |
Owner: Livingston Manor, Inc. Operator: Livingston Manor, Inc. Registered Agent: Hal F. Juckette |
Legal Action: Class I Notice of Noncompliance |
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Description: The facility failed to provide adequate supervision to prevent one resident from leaving the facility without staff knowledge. On 8/22/05 at approximately 5:15 a.m., facility staff heard a door alarm. The staff went to the door looked outside and not seeing anything turned off the door alarm. While staff prepared to get residents up, they noticed Resident #1 was missing. Facility staff found the resident in a field between a ditch and Highway 36 lying face down wearing a hospital type gown with no shoes, socks or undergarments. The left side of the resident’s face was red and appeared swollen near the brow area and his/her left knee appeared swollen. The resident was transferred to the local emergency room for evaluation. The emergency room discharge paperwork revealed head injury, although no evidence of injury serious enough to require hospitalization. Careful observation for the next 48 hours was advised. |
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Facility: Shady Lawn Nursing Home Savannah, MO 88-Bed Skilled Nursing Facility Date of Notice: September 2005 |
Owner: Andrew Co. Nursing Home District Operator: The Progressive Health Group, Inc. Registered Agent: James Lincoln |
Legal Action: Uncorrected Class II Notice of Noncompliance |
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Description: A survey was completed on 7/20/05. A revisit was completed on 9/12/05. The facility was not in substantial compliance with participation requirements in the following areas: Facility staff failed to complete comprehensive assessments (MDS) in a timely manner for three residents. Develop a plan of care to meet the needs of one resident. Update the plan of care for two residents to reflect interventions to address pressure sores and incontinence care. Follow standards of practice by continuing to administer insulin past the recommended discard date. Implement interventions as directed in the plan of care for three residents. Maintain 15 months of MDS assessments in the active record for three residents. Assure staff assessed and/or provided pressure relieving devices to prevent two residents from developing pressure sores. Assure staff correctly used assistive devices to prevent accidents during transfers for five residents. |
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Facility: Bristol Manor of Lexington Lexington, MO 12-Bed Residential Care Facility Date of Notice: September 2005 |
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: The facility failed to provide supervision for one resident who continued to smoke in his/her room. |
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Facility: Peals II Eden for Elders Princeton, MO 60-Bed Skilled Nursing Facility Date of Notice: September 2005 |
Owner: Not Listed Operator: Pearl’s II Eden for Elders, LLC Registered Agent: Rober C. Bagley |
Legal Action: Class I Notice of Noncompliance |
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Description: A complaint investigation was completed on 9/12/05. The facility was not in substantial compliance with participation requirements. Facility staff failed to provide adequate oversight and supervision for one dependent, confused resident with a history of elopements from leaving the facility without staff knowledge. On 9/4/05 while staff provided care to a resident, staff looked out the window and saw Resident #1 walking outside. By the time facility staff went outside, the resident was outside the fenced area and had walked approximately 50 feet from the gate, outside the north exit, across the grassy area at the edge of the woods. Five staff was on duty at the time of the incident and none of the staff reported hearing the door alarm sound when the resident exited the facility. Observation during the investigation revealed the door alarms sound at the panel located in the central living room and require staff to turn off the door alarm. |
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Facility: Sunnyview Nursing Home & Apartments Trenton, MO Date of Notice: October 2005 |
Owner: Grundy Co. Nursing Home Dist. Operator: Grundy Co. Nursing Home Dist. Registered Agent: Not Listed
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Legal Action: Class I Notice of Noncompliance |
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Description: The facility staff failed to obtain a physician ordered urinalysis in a timely manner and provide prompt medical attention for one resident (Resident #1). The resident showed symptoms of a Urinary Tract Infection and due to the delay in identification and treatment, developed septic shock and a coma resulting in the resident’s death. |
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Facility: Lake Viking Health Care Gallatin, MO 97-Bed Skilled Nursing Facility Date of Notice: November 2005 |
Owner: Daviess County Operator: N&R of Gallatin, Inc. Registered Agent: Charlotte Stutts |
Legal Action: Uncorrected Class II Notice of Noncompliance |
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Description: An annual survey was completed on 9/1/05. The facility was not in substantial compliance with participation requirements. A revisit was completed on 10/24/05. The facility staff failed to update resident care plan goals and approaches when residents experienced condition changes and failed to implement a system to identify, treat and prevent the spread of a highly communicable diseases. |
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Facility: Golden Age Nursing Home Braymer, MO 83-Bed Skilled Nursing Facility Date of Notice: November 2005 |
Owner: Golden Age Nursing Home Dist. Operator: Golden Age N.H. Dist. Registered Agent: Not Listed |
Legal Action: Uncorrected Class II Notice of Noncompliance |
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Description: An annual survey was completed at the facility on 8/23/05. The facility was not in substantial compliance with participation requirements. A revisit was completed on 10/17/05. The facility staff failed: develop a comprehensive care plan with specific interventions to address aggressive behaviors of one resident; to discard a multi-dose bottle of insulin which was outdated and still in use; train staff on the use of a standard recipe for the preparation of pureed foods; assure staff washed hands when going from soiled to clean tasks while providing care to residents. |
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Facility: Crestview Home, Inc. Bethany, MO 160-Bed Skilled Nursing Facility Date of Notice: November 2005 |
Owner: Harrison County Missouri Operator: Crestview Home, Inc. Registered Agent: Edward M. Manring |
Legal Action: Class I Notice of Noncompliance |
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Description: The facility failed to provide adequate oversight and supervision of one cognitively impaired resident, with a history of attempts to elope, from leaving the facility without staff knowledge. On 10/10/05, the resident, who had a wander guard bracelet on, exited the building without setting off a door alarm. Resident #1 went approximately 300 feet around the RCF portion of the building into the parking lot. Facility staff found the resident as they were leaving for work. |
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Facility: Lawson Manor & Rehab Lawson, MO 60-Bed Skilled Nursing Facility Date of Notice: November 2005 |
Owner: DCB Real Estate Partnership Operator: Lawson #1, Inc. Registered Agent: Not Listed |
Legal Action: Uncorrected Class II Notice of Noncompliance |
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Description: A survey was completed on 9/19/05. The facility was not in substantial compliance with participation requirements. A revisit was completed on 11/10/05. The facility staff failed to: Update a resident’s care plan after the resident developed a pressure sore. Elevate one resident’s heels at all times as ordered by the resident’s physician. Provide pressure relief for two residents and follow physician dressing change orders. Provide perineal care in a manner to prevent urinary tract infections for two residents. Assure staff used appropriate techniques to reduce the possibility of resident injury during transfers for four residents. Follow professional standards of hand washing during resident care for two residents. |
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Facility: Bristol Manor of Cameron Cameron, MO 12-Bed Residential Care Facility Date of Notice: November 2005 |
Owner: Bristol Care, Inc. Operator: Bristol Care, Inc. Registered Agent: David Furnell |
Legal Action: Uncorrected Class II Notice of Noncompliance |
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Description: A licensure inspection was completed on 8/16/05. The facility was not in substantial compliance with participation requirements. A revisit was completed on 11/16/05. The facility staff failed to date insulin vials when opened and discard insulin past the expiration date. |
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Facility: Royal Care Center, Inc. Excelsior Springs, MO 108-Bed Skilled Nursing Facility Date of Notice: December 2005 |
Owner: Royal Care Center, Inc. Operator: Royal Care Center, Inc. Registered Agent: Jesse J. Hwang |
Legal Action: Uncorrected Class II Notice of Noncompliance |
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Description: A survey was completed on 9/20/05. The facility was not in substantial compliance with participation requirements. A revisit was completed on 11/15/05. The facility staff failed to identify pressure sore risk factors and develop a plan of care for one resident. Also, the facility staff failed to implement measures to assure two residents with a history of pressure sores did not re-open or develop new pressure sores. |
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Facility: Elderhaus Inn Troy, MO 20-Bed Residential Care Facility Date of Notice: December 2005 |
Owner: Boden, Robert & Penny Operator: Robert Boden Registered Agent: None |
Legal Action: Uncorrected Class II Notice of Noncompliance |
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Description: An inspection was completed on 9/14/05. A revisit was completed on 11/16/05 and SLTC found the facility had uncorrected deficiencies as follows. The facility failed to ensure a safe and effective system of medication administration, failed to use acceptable techniques during administration of eye medication and failed to document why as needed medications were administered and if the medication was effective. |
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Facility: Perry County Nursing Home Perryville, MO 123-Bed Skilled Nursing Facility
Date of Notice: March 2005 |
Owner: County of Perry Operator: Perry County Nursing Home, Inc. Registered Agent: Carl I. Buchheit |
Legal Action: Uncorrected Class II Notice of Noncompliance
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Description: At the revisit on 3/2/05, the facility did not provide appropriate treatment and services to residents to increase range of motion and/or to prevent further decrease in range of motion. Physical therapy evaluations identified 37 residents needing range of motion exercises from nursing staff. Seven of those residents were reviewed and staff did not provide range of motion exercises to all seven residents. |
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Facility: Caruthersville Nursing Center Caruthersville, MO 94-Bed Skilled Nursing Facility Date of Notice: June 2005 |
Owner: Pemiscot County Memorial Hospital Operator: Pemiscot County Memorial Hosp. Registered Agent: Not Listed |
Legal Action: Uncorrected Class II Notice of Noncompliance |
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Description: A survey and annual inspection was completed on 3/30/05 and the revisit was completed on 5/24/05. The facility was not in substantial compliance due to uncorrected Class II violations. The facility failed to identify, assess and provide appropriate restorative nursing care to residents based on resident needs. The facility also failed to assess and provide interventions to meet the nutritional needs of residents fed through gastrostomy tubes. |
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Facility: Perry Oaks Manor, LLC Perryville, MO 156-Bed Skilled Nursing Facility Date of Notice: August 2005 |
Owner: L&H of Perryville, LLC Operator: Perry Oaks Manor, LLC Registered Agent: Sharo Shirshekan |
Legal Action: Uncorrected Class II Notice of Noncompliance |
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Description: At the revisit completed 8/2/05, the facility failed to correct all deficiencies. The facility failed to follow the facility approved menus and recipes when preparing meals and failed to follow tray cards when serving resident meals. The facility also failed to store, prepare and distribute foods under sanitary conditions increasing the risk of cross-contamination and food-borne illness. |
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Facility: Bristol Manor of Lamar Lamar, MO 12-Bed Residential Care Facility
Date of Notice: July 2005 |
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: The facility failed to ensure food served to residents was in sound condition free from contamination and safe for human consumption when evidence of heavy rodent infestation and rodent droppings were found in the facility’s kitchen and pantries. |
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Facility: Blue Castle of the Ozarks East Bolivar, MO 16-Bed Residential Care Facility Date of Notice: September 2005 |
Owner: Redd, Darren L. & Michelle R. Operator: Blue Castle of the Ozarks, Inc. Registered Agent: Michelle Redd |
Legal Action: Class I Notice of Noncompliance |
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Description: The facility admitted Resident with a history of sexually inappropriate behavior. Although the facility was aware of the resident’s behaviors at the time of admission, the facility did not instruct staff on how to deal with Resident #1’s behaviors. Resident #1 displayed sexually inappropriate behavior with seven residents including grabbing male and female residents’ private areas, exposing himself/herself to residents, entering other resident’s beds and touching them inappropriately. The facility failed to implement measures to address Resident #1’s sexually inappropriate behaviors and failed to notify the resident’s physician regarding the behaviors. |
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Facility: Dallas County Care Center Buffalo, MO 42-Bed Skilled Nursing Facility Date of Notice: November 2005 |
Owner: Deaconess Long Term Care of Ohio Operator: Deaconess Long Term of Ohio, Inc. Registered Agent: C T Corporation |
Legal Action: Class I Notice of Noncompliance |
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Description: The facility failed to provide adequate supervision for one resident who was sexually inappropriate. The resident touched and fondled multiple residents who also resided in the facility. |
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Facility: Villa Helen Marie Residential Care, Inc. St. Louis, MO 20-Bed Residential Care Facility
Date of Notice: January 2005 |
Owner: Henlon, Warren L. Operator: Villa Helen Marie Residential Care, Inc. Registered Agent: Rita M. Henlon |
Legal Action: Uncorrected Class II Notice of Non-compliance |
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Description: The facility failed to correct the following Class II deficiencies: Two-hour enclosed exit stairwells were not maintained; One resident in the facility is mentally unable to negotiate a normal path to safety. |
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Facility: Tower Village, Inc. St. Louis, MO 264-Bed Skilled Nursing Facility
Date of Notice: January 2005 |
Owner: Tower Village, Inc. Operator: Tower Village, Inc. Registered Agent: Carol A. Weir |
Legal Action: Uncorrected Class II Notice of Non-compliance |
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Description: The facility failed to correct deficiencies in the areas of resident care and construction standards. The facility’s medication administration error rate was 10%. Staff failed to follow residents’ physician orders resulting in missed labs and outdated treatments. The facility failed to properly treat and assess residents’ pressure sores and significant weight losses. The facility failed to maintain hot water temperatures less than 120 degrees Fahrenheit. |
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Facility: Grand Manor Nursing & Rehabilitation Center St. Louis, MO
120-Bed Skilled Nursing Facility
Date of Notice: January 2005 |
Owner: Grand Manor Property, LLC Operator: Grand Manor Nursing & Rehab Center, LLC Registered Agent: Mark S. Rubin |
Legal Action: Uncorrected Class II Notice of Non-compliance |
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Description: The facility failed to maintain the elevator room in compliance with the Life Safety Code, which requires elevator equipment to be in accordance with ASME/ANSI standards. The facility did not have a smoke detector which was hard wired to the fire alarm panel, in the elevator room. |
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Facility: Oak Forest Skilled Care Ballwin, MO 66-Bed Skilled Nursing Facility
Date of Notice: February 2005 |
Owner: Oak Forest Skilled Care LLC Operator:
Cathedral Rock of Ballwin, Inc. |
Legal Action: Class I Notice of Noncompliance |
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Description: A confused ambulatory resident with a history of wandering and going toward exit doors, eloped from the facility early in the morning on 1/31/05. The resident was observed by staff between 5:00 a.m. and 5:30 a.m. in the facility. At 6:20 a.m. staff could not locate the resident. The outside temperature was 29 degrees Fahrenheit (F) and the resident wore only a nightgown and slipper socks. The resident was found at approximately 7:10 a.m. behind the facility down a muddy hill dense with brush and sustained scratches and bruises. His/her body temperature was 95.2 degrees F. Staff did not know how the resident left the facility. Staff did not hear a door alarm, and the key was left in one of the alarms. |
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Facility: Loving Care Home St. Louis, MO 109-Bed Residential Care Faciltiy Date of Notice: March 2005 |
Owner: Loving Care Rest Home, Inc. Operator: The Stone & Daniels Corp. Registered Agent: Larry Daniels |
Legal Action: Class I Notice of Noncompliance |
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Description: The facility failed to intervene and seek emergency medical attention for one resident who was unresponsive for over an hour. The facility transferred the resident to the hospital, where he/she remained in a coma for sixteen days until his/her death. |
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Facility: St. Elizabeth Healthcare & Rehab Center Florissant, MO 150-Bed Skilled Nursing Facility Date of Notice: March 2005 |
Owner: Florissant Property, LLC Operator: St. Elizabeth Healthcare & Rehab Center, LLC Registered Agent: Robin Suydam |
Legal Action: Uncorrected Class II Notice of Non-compliance |
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Description: The facility failed to correct the following deficiencies: Resident rooms and resident use areas were not clean and well maintained. Residents dependent upon staff for care needs were not provided good grooming and personal hygiene. Residents with indwelling urinary catheters were not assessed for the need of the catheters and the catheter tubing and bags were not positioned by staff in a manner to provide for good drainage. Residents with contractures were not provided with appropriate devices and range of motion exercises to prevent worsening of the contractures. Residents were not properly transferred and assessed by staff to prevent accidents with injuries. |
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Facility: The Woodlands of Maryland Heights Maryland Heights, MO 120-Bed Skilled Nursing Facility Date of Notice: April 2005 |
Owner: Ripley-Spence Properties No. 2, LLC Operator: Ripley-Spence Properties No. 2, LLC Registered Agent: Charles J. Riley |
Legal Action: Class I Notice of Noncompliance |
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Description: The facility failed to provide appropriate care for one resident by not assessing the resident’s condition and notifying the physician. The facility did not recognize the resident’s need for immediate medical attention even though the resident became unresponsive. The resident was admitted to the hospital in critical condition with diagnoses including sepsis and renal failure. |
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Facility: New Heights Residential Care St. Louis, MO 30-Bed Residential Care Facility Date of Notice: May 2005 |
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: The facility failed to correct the following deficiencies: Exit doors were equipped with more than one simple lock and one exit door could not be opened; The facility did not have all resident fund records maintained on the facility premises. |
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Facility: Bernard Care Center St. Louis, MO 141-Bed Skilled Nursing Facility Date of Notice: May 2005 |
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: The facility failed to correct the following deficiencies: Laboratory tests ordered by residents’ physicians were not obtained; The medication error rate was more than 5%. |
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Facility: Delmar Gardens of Chesterfield Chesterfield, MO 240-Bed Skilled Nursing Facility Date of Notice: May 2005 |
Owner: DGCH, Inc. Operator: Delmar Gardens of Chesterfield Operating, Inc. Registered Agent: Husch Registered Agent, Inc. |
Legal Action: Class I Notice of Noncompliance |
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Description: The facility failed to adequately assess and provide interventions for one resident who experienced a significant change in condition. The resident experienced episodes of brown emesis and diarrhea one night between approximately 12:30 a.m. until 6:00 a.m. Staff did not adequately assess and monitor the resident, turn off the resident’s tube feeding or notify the physician. At approximately 6:00 a.m., the resident vomited more brown substance and had no vital signs. Staff did not initiate full emergency procedures or call 9-1-1. The resident died at the facility on 4/25/05 at approximately 6:20 a.m. |
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Facility: Scenic Nursing & Rehab Center, LLC Herculaneum, MO 166-Bed Skilled Nursing Facility Date of Notice: May 2005 |
Owner: HCRI Missouri Properties, LLC Operator: Scenic Nursing & Rehab Center, 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 supervision for one resident who eloped from the secured Alzheimer’s unit of the facility. The resident, who repeatedly spoke of going home and exhibited exit seeking behaviors, left the facility through an alarmed door without staff knowledge, walked 2.3 miles on a two-lane road into the next town before staff found him/her at a main intersection. |
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Facility: Hillcrest Care Center, Inc. DeSoto, MO 120-Bed Skilled Nursing Facility Date of Notice: June 2005 |
Owner: DeSoto Health Care, Inc. Operator: Hillcrest Care Center, Inc. Registered Agent: Brad Queen |
Legal Action: Class I Notice of Noncompliance |
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Description: The facility staff failed to notify one resident’s physician of a swollen, painful and discolored hand. The facility staff failed to monitor and assess the resident’s hand. On 5/4/05 facility staff sent the resident to the hospital where he/she was diagnosed with an ischemic (lack of oxygen), gangrenous, mummified right hand. On 5/5/05, the hospital performed an above the elbow amputation of the resident’s right arm due to the damage to the right hand and forearm muscles. The resident suffered an arterial embolus (blood clot) to her right brachial (arm) artery. |
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Facility: Big Bend Woods Healthcare Center Valley Park, MO 176-Bed Skilled Nursing Facility Date of Notice: June 2005 |
Owner: Monarch Properties, LP Operator: Cedarcroft Health Services, Inc. Registered Agent: CT Corporation System |
Legal Action: Uncorrected Class II Notice of Noncompliance |
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Description: The facility failed to prevent the commingling of resident funds with facility funds and failed to establish and maintain a system that assured a full, complete and separate accounting of each resident’s personal funds. The facility failed to deposit 21 resident’s funds in an account separate from the facility operating account and failed to credit and post all interest earned on 21 resident’s funds. The facility failed to notify six residents whose accounts were within $200 of the SSI limit. |
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Facility: The Woodlands of Maryland Heights Maryland Heights, MO 120-Bed Skilled Nursing Facility Date of Notice: June 2005 |
Owner: Riley-Spence Properties No. 2, LLC Operator: Riley-Spence Properties No. 2, LLC Registered Agent: Charles J. Riley |
Legal Action: Uncorrected Class II Notice of Noncompliance |
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Description: The facility failed to correct the following deficiencies: Residents were not provided appropriate care and services and treat pressure sores and other wounds. Residents were not assessed and the physician notified of a change in condition. Physician orders were not followed regarding positioning devices, pressure relieving devices and personal safety alarms. |
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Facility: Haven Meadows Care Center Florissant, MO 120-Bed Skilled Nursing Facility Date of Notice: June 2005 |
Owner: OGG-Missouri Ltd. Operator: Cathedral Rock of Florissant, Inc. Registered Agent: Anthony J. Soukenik |
Legal Action: Uncorrected Class II Notice of Compliance |
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Description: The facility failed to provide completed coverage for all portions of the building by not sprinklering the walk-in refrigerator and freezer. |
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Facility: Manorcare Health Services Florissant, MO 98-Bed Skilled Nursing Facility Date of Notice: July 2005 |
Owner: Manorcare Health Services, Inc. Operator: Manorcare Health Services, Inc. Registered Agent: CT Corporation System |
Legal Action: Uncorrected Class II Notice of Noncompliance |
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Description: The facility failed to maintain a complete sprinkler system and failed to conduct thorough investigations into injuries of unknown origin for three residents. |
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Facility: Affton Residential Care Facility Affton, MO 19-Bed Residential Care Facility Date of Notice: July 2005 |
Owner: Sienkiewicz, Inc. Operator: Sienkiewicz, Inc. Registered Agent: Not Listed |
Legal Action: PROBATIONARY LICENSE SURRENDER effective August 15, 2005 |
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Facility: Pacific Care Center, Inc. Pacific, MO 120-Bed Skilled Nursing Facility Date of Notice: July 2005 |
Owner: Pacific Care Center, Inc. Operator: Pacific Care Center, Inc. Registered Agent: Robert E. Schmidt |
Legal Action: Uncorrected Class II Notice of Noncompliance |
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Description: A survey was completed on 5/20/05. A revisit was conducted on 7/6/05, which found the facility was not in substantial compliance with participation requirements. Facility staff failed to provide adequate supervision and assistive devices as directed by the resident’s plan of care and the resident’s physician to prevent accidents for one resident to prevent falls and injuries. |
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Facility: The Abbey Care Center St. Louis, MO 126-Bed Skilled Nursing Facility Date of Notice: July 2005 |
Owner: J & J Associates, LLC Operator: Fairfield Nursing & Rehab, Inc. Registered Agent: Charlotte Stutts |
Legal Action: Uncorrected Class II Notice of Noncompliance |
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Description: The facility failed to correct the following deficiencies: Exit and directional signs were not equipped with functioning emergency backup lighting. The electrical wiring was not maintained in accordance with the National Electric Code. Designated exit doors were not maintained free from obstructions. Corridor doors were not maintained smoke tight. Facility staff failed to investigate injuries of unknown origin. Physician orders were not followed. Residents were not provided appropriate care to prevent and treat pressure sores. |
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Facility: The Abbey Care Center St. Louis, MO 126-Bed Skilled Nursing Facility Date of Notice: August 2005 |
Owner: J&J Associates, LLC Operator: Fairfield Nursing & Rehab, Inc. Registered Agent: Charlotte Stutts |
Legal Action: Uncorrected Class II Notice of Noncompliance |
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Description: The facility failed to provide appropriate care to treat and prevent pressure sores. |
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Facility: St. Elizabeth Hall St. Louis, MO 50-Bed Residential Care Facility Date of Notice: August 2005 |
Owner: Archdiocese of St. Louis Operator: Cardinal Ritter Institute Residential Services Registered Agent: Sister Suzanne Wesley, CSJ |
Legal Action: Uncorrected Class II Notice of Noncompliance |
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Description: The facility failed to obtain laboratory work every two weeks, as ordered by one resident’s physician. |
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Facility: Lutheran Senior Services at Breeze Park St. Charles, MO 65-Bed Skilled Nursing Facility Date of Notice: August 2005 |
Owner: Lutheran Senior Services Operator: Lutheran Senior Services Registered Agent: Not Listed |
Legal Action: Class I Notice of Noncompliance |
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Description: The facility failed to provide adequate supervision and assistance for one resident who was unable to sit independently. Staff transferred the resident onto the toilet and failed to provide physical support for balance. The resident fell and suffered a broken neck, which was determined to be a factor in her death three weeks later. |
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Facility: Pacific Care Center, Inc. Pacific, MO 120-Bed Skilled Nursing Facility Date of Notice: August 2005 |
Owner: Pacific Care Center, Inc. Operator: Pacific Care Center, Inc. Registered Agent: Robert E. Schmidt |
Legal Action: Class I and Uncorrected Class II Notice of Noncompliance |
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Description: A survey was completed on 5/20/05. Revisits were completed on 7/6/05 and 8/8/05. The facility was not in substantial compliance. Facility staff failed to provide adequate supervision and ensure smoking regulations were followed to provide for the safety of residents in the smoking area. Facility staff failed to ensure smoking was prohibited from areas where oxygen was used or stored and failed to prevent one resident from accessing oxygen while smoking, resulting in burns to the resident’s face. |
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Facility: Delhaven Manor St. Louis, MO 156-Bed Skilled Nursing Facility Date of Notice: September 2005 |
Owner: AGI Delhaven Manor Operator: Delhaven Manor No. 2, Inc. Registered Agent: Lonnie G. Hasty |
Legal Action: Uncorrected Class II Notice of Noncompliance |
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Description: The facility failed to correct the following deficiencies: The facility staff failed to provide a safe and effective system of distributing medications. Residents were given medications without a physician’s order. Physicians’ orders were not followed. Residents were not provided appropriate care and services to prevent injuries. Residents with pressure sores were not provided care to treat current pressure sores and care to prevent the development of new pressure sores. Residents were not served foods at appropriate temperatures and in accordance with physician ordered diets. The facility staff did not maintain the physical environment clean and in good repair including walls, floors, furniture and resident equipment. |
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Facility: Autumn Ridge Herculaneum, MO 69-Bed Residential Care Facility Date of Notice: September 2005 |
Owner: Autumn Ridge Herculaneum, LLC Operator: Emeritus Corporation Registered Agent: CT Corporation System |
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 assure each resident was able to physically and mentally negotiate a normal path to safety. The facility housed residents who required walkers for ambulation and blind residents to live on a wing where the nearest exit required residents to negotiate stairs to exit to grade. The facility failed to assure residents’ physician orders were followed. |
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Facility: Dutchtown Care Center St. Louis, MO 120-Bed Skilled Nursing Facility Date of Notice: November 2005 |
Owner: A.F.T., Inc. Operator: Dutchtown Care Center, Inc. Registered Agent: Carl C. Lang |
Legal Action: Class I Notice of Noncompliance |
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Description: The facility failed to provide pressure reducing devices, failed to provide treatments as ordered and failed to identify, assess and monitor one resident’s pressure ulcers resulting in two Stage IV pressure ulcers, which exposed bone, tissue and muscle. On 10/13/05, during a wound assessment initiated by the surveyor, a pressure ulcer on the resident’s ankle measured 5.5 centimeters (cm) by 3.0 cm. Review of the facility wound reports and treatment records showed staff did not document an assessment of this pressure ulcer since 8/24/05. During the assessment, SLTC and facility staff observed a bleeding and necrotic pressure ulcer between the resident’s toes. The pressure ulcer was uncovered and untreated. The facility treatment nurse said she was unaware of the pressure ulcers in between the resident’s toes. |
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Facility: Autumn Ridge Herculaneum, MO 69-Bed Residential Care Facility Date of Notice: December 2005 |
Owner: Autumn Ridge Herculaneum, LLC Operator: Emeritus Corporation Registered Agent: CT Corporation System |
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 assure each resident was able to physically and mentally negotiate a normal path to safety. The facility housed residents who required walkers for ambulation and blind residents to live on a wing where the nearest exit required residents to negotiate stairs to exit to grade. |
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Facility: Sunrise of Chesterfield Chesterfield, MO 95-Bed Intermediate Care Facility Date of Notice: December 2005 |
Owner: Sunrise Chesterfield Assisted Living Operator: Sunrise Third (Pool 1) LLC Registered Agent: C T Corporation System |
Legal Action: Class I Notice of Noncompliance |
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Description: The facility failed to follow one resident’s physician’s order for a seven-day course of antibiotics to treat cellulitis (skin infection). The facility administered the antibiotic for 27 days. The resident suffered diarrhea, dehydration and Clostridium difficile as a result of the continued administration of the antibiotic. The resident died on 11/28/05. The resident’s physician listed the immediate cause of death as Clostridium difficile/colitis. |
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Facility: Carondelet Retirement Manor, Inc. St. Louis, MO 33-Bed Residential Care Facility Date of Notice: December 2005 |
Owner: Carondelet Retirement Manor, Inc. Operator: Carondelet Retirement Manor, Inc. Registered Agent: Lela C. Scauzzo |
Legal Action: Uncorrected Class II Notice of Noncompliance |
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Description: The facility failed to correct the following deficiencies: Cigarette waste was not disposed of properly, creating a fire hazard. Emergency lights were not maintained in working order. Ceilings in resident use areas were in disrepair. |
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Facility: Grand Manor Nursing & Rehabilitation St. Louis, MO 120-Bed Skilled Nursing Facility Date of Notice: December 2005 |
Owner: Grand Manor Property, LLC Operator: Grand Manor Nursing & Rehab Registered Agent: Mark S. Rubin |
Legal Action: Class II Notice of Noncompliance |
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Description: The facility failed to maintain facility floors, walls, and equipment in good repair and to provide a homelike environment. The facility failed to follow physician orders regarding medications, tube feedings, the application of bed and wheelchair alarms, and treatments. The facility failed to provide necessary care and services by providing antibiotic therapy as ordered, providing appropriate interventions for a resident with a temperature and a wound. The facility failed to follow a resident’s order for continuous tube feeding and failed to provide a nebulizer in a timely fashion for a resident who was experiencing shortness of breath. The facility failed to provide therapeutic diets as ordered, failed to provide a resident with thickened liquids as ordered and failed to monitor a resident on fluid restrictions. The facility had a medication error rate of 22.64%. |
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