ST. LOUIS REGION

Facility:  Page Manor

St. Louis, MO

45-Bed Residential Care Facility

Date of Notice:  January 2006

Owner: Malik Home, LLC

Operator: Malik Home, LLC

Registered Agent: Saleh Malik

Legal Action: Uncorrected Class II Notice of Non-compliance

Description: The facility failed to correct the following deficiencies:  Fire extinguishers were not maintained. Smoke barrier doors separating floors did not close properly. Smoke barrier doors were held open with unapproved devices. Sprinkler heads were not maintained in accordance with NFPA 13. Residents who smoke were not adequately supervised. Resident rooms and other resident use areas were not clean and well maintained. Furniture and equipment were not clean and in good repair. Adequate storage was not provided for resident belongings. The operator did not ensure compliance with regulations. The contact information for each resident's physician was not obtained and kept in the residents' records. Employees did not wear identification badges while working. Employee records were not maintained as required. The facility did not employ a licensed nurse for the required number of hours. Residents' physicians were not notified of laboratory results. The facility staff failed to administer medications without error. Effective measures were not taken to prevent the infestation of rodents. Openings into the building were not protected from the entrance of rodents. Food was not handled in a manner to prevent contamination. Non-food contact services in the kitchen were not maintained in clean condition. Food contact surfaces in the kitchen were not maintained in clean condition.

Facility: Autumn Ridge

Herculaneum, MO

69-Bed Residential Care Facility

Date of Notice: February 2006

Owner: MLD Delaware Trust

Operator: Emeritus Corporation

Registered Agent: CT Corporation System

Legal Action: Uncorrected Class II Notice of Noncompliance

Description: The facility failed to correct the following deficiencies: The facility housed residents who required walkers for ambulation on a wing where the nearest exit required residents to negotiate stairs to exit to grade.

Facility: Northgate Park Nursing Home

Florissant, MO

156-Bed Skilled Nursing Facility

Date of Notice: February 2006

Owner: Not Listed

Operator: Prime Care Six, LLC

Registered Agent: LexisNexis Document Solutions Inc.

Legal Action: Class I Notice of Noncompliance

Description: The facility staff failed to provide suctioning and oxygen for a resident in respiratory distress. The staff did not have emergency equipment readily available and did not obtain prompt emergency medical care for the resident. When paramedics arrived at the facility, the resident's mouth and lungs were full of secretions and the resident died in the emergency room within one hour of arrival.

Facility: The Riverview

St. Louis, MO

120-Bed Skilled Nursing Facility

Date of Notice: February 2006

Owner: Not Listed

Operator: KJD Incorporation

Registered Agent: Carl C. Lang

Legal Action: Uncorrected Class II Notice of Noncompliance

Description: The facility was uncorrected based on their failure to ensure the following: One resident did not receive Remeron (an antidepressant) as ordered by his/her physician. The resident also did not receive his/her Lasix (a diuretic) as ordered by the physician in response to the resident's increased edema. One resident did not receive Lisinopril (used to treat hypertension) and Aldactone (diuretic used to treat hypertension and congestive heart failure) from 2/1/06-2/8/06, as ordered by his/her physician. One resident, with a history of weight loss, did not receive his/her nutritional supplement as ordered by the resident's physician. Facility staff failed to maintain the medication cart in a safe manner. One resident did not receive treatment as ordered by his/her physician for ulcers on his/her foot and facility staff failed to obtain laboratory tests as ordered for the resident.

Facility: Northgate Park Nursing Home

Florissant, MO

158 Bed Skilled Nursing Facility

Date of Notice: March 2006

Owner: Not Listed

Operator: Prime Care Six, LLC

Registered Agent: LexisNexis Document Solutions Inc.

Legal Action: Class I Notice of Noncompliance

Description: The facility failed to conduct and document a thorough assessment of a resident, failed to communicate adequate information to the resident's physician after repeated episodes of emesis and failed to administer an adequate supplemental oxygen supply when the resident was in respiratory distress. The resident died on the way to the emergency room.

Facility: Union Manor

St. Louis, MO

52 Bed Residential Care Facility

Date of Notice: March 2006

Owner: Cook, Alma

Operator: LaTerryl Saddler

Registered Agent: Alma Cook

Legal Action: Class I Notice of Noncompliance

Description: The facility failed to protect residents from verbal and physical abuse by two employees. Eight of ten residents interviewed witnessed or were victims of verbal or physical abuse by the operator of the facility and an aide employed at the facility.

Facility: Charlevoix Healthcare Center

St. Charles, MO

142-Bed Skilled Nursing Facility

Date of Notice: April 2006

Owner: Senior Trust of Charlevoix

Operator: Seniortrust of Charlevoix, LLC

Registered Agent: National Registered Agents, Inc.

Legal Action: Class I Notice of Noncompliance

Description: The facility failed to intervene and implement interventions to protect one resident who was repeatedly subjected to sexually inappropriate behavior from a family member. The resident had a history of chronic mental illness with accompanying impaired judgment and decision-making abilities. Facility staff were knowledgeable of the sexually inappropriate behavior and failed to report the incidents and failed to conduct an investigation.

Facility: Union Manor

St. Louis, MO

52-Bed Residential Care Facility

Date of Notice: April 2006

Owner: Alma Cook

Operator: Alma Cook

Registered Agent: None

Legal Action: Class I Notice of Noncompliance

Description: The facility failed to protect the health, safety and welfare of one resident who required oversight and supervision with medication and care. The facility informed the resident of an emergency discharge without adequate reason and without ensuring the safety of the patient.

Facility: Cori Manor

Fenton, MO

22-Bed Residential Care Facility

Date of Notice: April 2006

Owner: Cori Manor Assoc. Tenn. Gen Prtn

Operator: Affiliated Healthcare, Inc.

Registered Agent: Robert I. Falk

Legal Action: Uncorrected Class II Notice of Noncompliance

Description: A licensure inspection was completed on 2/10/06. The facility was not in substantial compliance. A revisit was completed on 4/13/06. The facility staff failed to maintain unobstructed fire exits, maintain the facility roof in good repair, ensure all opening to the outside screened or protected to prevent the entrance of insects, ensure dietary staff wore effective hair restraints, prohibit live animals in the dining room during meal service, protect food from potential contamination and failed to thaw frozen foods in a refrigerator or under potable running water.

Facility: Cori Manor

Fenton, MO

124-Bed Skilled Nursing Facility

Date of Notice: April 2006

Owner: Cori Manor Assoc. Tenn. Gen Prtn

Operator: Affiliated Healthcare, Inc.

Registered Agent: Robert I. Falk

Legal Action: Uncorrected Class II Notice of Noncompliance

Description: A survey was completed on 2/10/06. The facility was not in substantial compliance with participation requirements. A revisit was completed on 4/13/06. The facility staff failed to maintain floors, walls, doors and equipment and furniture in good repair. Facility staff failed to provide a thorough assessment of the resident's condition following a fall, obtain physician orders for treatment and accurately record medication administration for four residents. Also, the facility staff failed to protect food from potential contamination.

Facility: The Central Residence

St. Louis, MO

41-Bed Residential Care Facility

Date of Notice: April 2006

Owner: Garcia's Central Residence, LLC

Operator: Same

Registered Agent: Robert T. West

Legal Action: Class I Notice of Noncompliance

Description: The facility failed to provide adequate care to meet one resident's needs. The facility failed to administer medications as ordered by the resident's physician and adequately monitor a resident who experienced a change in condition. While waiting for emergency personnel the facility failed to monitor the resident's condition and immediately initiate cardio-pulmonary resuscitation when necessary. The resident expired on 3/6/06.

Facility: Autumn Ridge

Herculaneum, MO

69-Bed Residential Care Facility

Date of Notice: April 2006

Owner: Not Listed

Operator: Emeritus Corporation

Registered Agent: CT Corporation System

Legal Action: Uncorrected Class II Notice of Noncompliance

Description: A licensure inspection was completed on 6/9/05. Revisits were completed on 9/7/05, 11/28/05, 2/9/06 and 4/13/06. The facility is not in substantial compliance with participation requirements. The facility staff failed to ensure one resident was mentally and physically capable of negotiating a path to safety. Also, the facility failed to place ten residents who used walkers for ambulation or wheelchairs on a floor which has direct access to grade with a handrail in a non-sprinkled building.

Facility: Union Manor

St. Louis, MO

52-Bed Residential Care Facility

Date of Notice: April 2006

Owner: Not Listed

Operator: Alma Cook

Registered Agent: None

Legal Action: Class I Notice of Noncompliance

Description: The facility (sic) to protect residents from verbal and physical abuse and failed to follow the plan of correction developed by the facility Administrator.

Facility: Bellefontaine Gardens Nursing & Rehab

St. Louis, MO

96-Bed Skilled Nursing Facility

Date of Notice: May 2006

Owner: St. Louis Care LLC

Operator: Bellefontaine Gardens Nursing & Rehab, Inc.

Registered Agent: James Lincoln

Legal Action: Uncorrected Class II Notice of Noncompliance

Description: A survey was completed on 3/15/06. The facility was not in substantial compliance with participation requirements. A revisit was completed on 5/5/06. The facility staff failed to obtain physician orders and failed to monitor catheters and a tracheostomy. The facility failed to provide medications and oxygen as ordered for five residents. In addition, the facility failed to assess, monitor, provide follow-up care and notify the physician or family for four residents.

Facility: Cori Manor

Fenton, MO

124-Bed Skilled Nursing Facility

Date of Notice: June 2006

Owner: Cori Manor Associates, Tennessee Gen. Prtn.

Operator: Affiliated Healthcare, Inc.

Registered Agent: Robert I. Falk

Legal Action: Uncorrected Class II Notice of Noncompliance

Description: A licensure inspection was completed on 2/10/06. The facility was not in substantial compliance with participation requirements. Revisits were completed on 4/13/06 and 6/09/06. The facility staff failed to keep ceiling tiles, floors, walls, doors and furniture clean and in good repair in residents' rooms, two dining rooms, shower rooms and one corridor. As a result of the continued non-compliance the facility has been issued a directed plan of correction to correct the violations.

Facility: St. Louis Avenue Nursing Center

St. Louis, MO

90-Bed Skilled Nursing Facility

Date of Notice: June 2006

Owner: EBG Health Care II, Inc.

Operator: Same

Registered Agent: Ewing B. Gourley

Legal Action: Uncorrected Class II Notice of Noncompliance

Description: An annual survey was completed on 4/10/06. The facility was not in substantial compliance with participation requirements. A revisit was completed on 5/26/06. The facility staff failed to: provide written notification of discharge from the facility for one resident; facility staff failed to respond to residents in a respectful manner and cover or drape residents during personal care; maintain a clean, comfortable and homelike environment; develop plans of care to address the residents needs based on their comprehensive assessments; provide proper incontinence care for four residents; provide assess, provide treatment and pressure reduction devices to six residents at risk for pressure sore development; provide adequate supervision and monitoring to one resident who climbed over the roof and left the facility without staff knowledge; ensure a medication error rate of less than 5%; ensure staff washed their hands after providing care to five residents.

Facility: Christian Care Home

Ferguson, MO

180-Bed Skilled Nursing Facility

Date of Notice: August 2006

Owner: Christian Women's Benevolent Assoc.

Operator: Same

Registered Agent: Not Listed

Legal Action: Uncorrected Class II Notice of Noncompliance

Description: A survey was completed on 5/19/06. The facility was not in compliance with participation requirements. A revisit was completed on 7/27/06. The facility staff failed to monitor, report changes in condition and correctly administer medication for two residents. Staff failed to correctly administer Duragesic patches to one resident resulting in the resident having three patches on at one time. The resident was transferred to the hospital on 7/8/06 with respiratory distress. The hospital staff discovered the three patches and removed them and administered Narcan (a medication to reverse the effects of opiates, including breathing depression and sedation). In addition staff failed to administer two medications to another resident who experienced chest pain and shortness of breath.

Facility: The Riverview

St. Louis, MO

120-Bed Skilled Nursing Facility

Date of Notice: September 2006

Owner: Not Listed

Operator: KJD Incorporated

Registered Agent: Carl C. Lang

Legal Action: Class I Notice of Noncompliance

Description: The facility failed to monitor and ensure the safety of one resident (Resident #1) who exhibited delusional behaviors and expressed suicidal ideations. The resident was sent for evaluation on 8/12/06, and returned to the facility with a diagnosis of acute delirium with dementia and no changes were made to current medications. Facility staff failed to notify the physician and/or psychiatrist of the resident's return. The resident continued to exhibit delusional behaviors and stated he/she wanted to leave the facility. On 8/18/06, the resident went out the fourth floor window of his/her room and fell to his/her death.

Facility: Nursing & Rehab Center of U-City Loop

University City, MO

130-Bed Skilled Nursing Facility

Date of Notice: September 2006

Owner: Not Listed

Operator: Nursing & Rehab Center of U-City Loop, LLC

Registered Agent: Sharo Shirshekan

Legal Action: Class I Notice of Noncompliance

Description: The facility failed to notify the physician of a resident's attempts to elope. The facility failed to monitor and ensure the safety of one resident, who expressed the need to escape from the building and had a history of previous elopement attempts. The resident had attempted to leave the building on three occasions and staff implemented 15-minute checks. On 8/11/06 staff found the resident in the stairwell again. The resident told staff he/she knew he/she could not use the stairs or elevator, but would find a way to leave the building. Facility staff did not notify the resident's physician of the elopement attempts. On 8/13/06 at approximately 8:30 p.m., the resident attempted to escape from his/her third floor bedroom window and fell to his/her death. In addition the facility failed to notify a resident's legal representative of the resident's elopement from the facility, transfer to hospital and findings of a fracture.

Facility: Autumn View Gardens at Schuetz Road

St. Louis, MO

100-Bed Assisted Living Facility

Date of Notice: December 2006

Owner: Not Listed

Operator: Bethesda Foundation

Registered Agent: C T Corporation System

Legal Action: Class I & Uncorrected Class II Notice of Noncompliance

Description: A complaint investigation was completed on 9/06/06. The facility was not in substantial compliance with participation requirements. A revisit and complaint investigation was completed on 12/08/06. The facility failed to provide adequate oversight and supervision to one resident. The resident left the facility on two occasions, 12/02/06 and 12/03 through 12/04/06, unattended while the outside temperatures were below freezing, the sidewalks were covered in snow and it was dark outside.

Facility: Mason Manor

St. Louis, MO

12-Bed Residential Care Facility

Date of Notice: December 2006

Owner: Not Listed

Operator: Cura, Inc.

Registered Agent: Timothy G. Dolan

Legal Action: Class I Notice of Noncompliance

Description: Facility staff failed to ensure nine of nine residents could make an unassisted pathway to safety.

Facility: Parkview Residential Care

Crystal City, MO

52-Bed Residential Care Facility

Date of Notice: December 2006

Owner: Crystal City

Operator: DMP Enterprises, Inc.

Registered Agent: Mark C. Goldenberg

Legal Action: Class I & Uncorrected Class II Notice of Noncompliance

Description: A licensure inspection was completed on 9/19/06. The facility was not in substantial compliance with participation requirements. A complaint investigation and revisit was completed on 12/8/06. The facility failed maintain (sic) the temperature in the building above 68 degrees Fahrenheit. On 12/8/06 residents were observed wearing coats, hats and gloves during the breakfast meal. The temperature in the building measured between 56 and 60 degrees F. Also, the facility failed to maintain two unobstructed exits on the second floor.