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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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