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Missouri Long-term Care Facility

Notices of Non-Compliance

2005

2005 Nursing Home Non-Compliance by Region:

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

NORTHEAST REGION

 

Facility: 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

 

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.

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

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.

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

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.

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

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.

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

Description:† The facility failed to prevent storage of combustible materials in the attic and in the furnace room.

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

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.

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

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.

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

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 residentsí electrical appliances. Many outlets had surge protectors plugged into a duplex outlet. The surge protectors had as many as six appliances plugged into them.

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

Description: The facility failed to ensure water temperatures at plumbing fixtures remained between 105 degrees Fahrenheit and 120 degrees Fahrenheit.

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

Description: Facility staff failed to follow physicianís 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.

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

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 residentís 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.

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

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.

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

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%.

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

Description:† The facility failed to provide appropriate care to one residentís 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.

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

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.

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

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 residentís bed or chair, failed to develop a plan of care and failed to thoroughly assess one residentís pressure ulcers, which resulted in numerous stage II, II and IV pressure ulcers.

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

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.

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

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.

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

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.