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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: 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 Staff failed to follow residents’ physician orders resulting in missed labs and outdated treatments.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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