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Return to MCQC Nursing Home Non-Compliance Page
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Missouri Long-term Care Facility Notices of Non-Compliance 2008 |
2008 Nursing Home Non-Compliance by Region: 1. Southwest Region |
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CENTRAL REGION | ||
| Facility:
Golden Livingcenter-Jefferson City
Jefferson City, MO 87-Bed Skilled Nursing Facility Date of Notice: February 2008 |
Owner: Beverly
Enterprises MO Inc.
Operator: GGNSC Jefferson City LLC Registered Agent: CSC-Lawyers Incorporating Service Company |
Legal Action: Class I Notice of Noncompliance |
| Description: A complaint investigation was completed on 2/04/08. The facility was not in substantial compliance with participation requirements. The facility staff failed to assess a resident after a report that the resident was “unresponsive and cold.” Also the facility staff failed to continue Cardio-Pulmonary Resuscitation on the resident who had an advance directive for full code status until emergency responders arrived. | ||
| Facility:
Jefferson Lodge
Fulton, MO 94-Bed Skilled Nursing Facility Date of Notice: March 2008 |
Owner: Rescare
of Missouri Inc.
Operator: Same Registered Agent: Eric F. Fink, Jr. |
Legal Action: Uncorrected Class II Notice of Noncompliance |
| Description: The facility failed to provide a safe and effective medication system by failing to administer and document medications according to physician’s orders for three of six residents reviewed. | ||
| Facility:
Rest Haven Conv & Retirement Home
Sedalia, MO 86-Bed Skilled Nursing Facility Date of Notice: April 2008 |
Owner: John T.
Finley, Inc.
Operator: John T. Finley, Inc. Registered Agent: John C. Finley |
Legal Action: Uncorrected Class II Notice of Noncompliance |
| Description: A complaint investigation was completed on 2/14/2008. At the time of the revisit, the facility failed to ensure drug regimen reviews were completed on a monthly basis as required. The Administrator and Director of Nursing stated the facility had not had a pharmacist since 11/2007 to complete the drug regimen reviews for any of the residents in the facility. The census at the time of the revisit was 43 residents. | ||
| Facility:
Jefferson Lodge
Fulton, MO 94-Bed Residential Care Facility Date of Notice: May 2008 |
Owner: Rescare
of Missouri, Inc.
Operator: Same Registered Agent: Eric F. Fink, Jr. |
Legal Action: Class I and Uncorrected Class II Notice of Noncompliance |
| Description: On 1/23/08, SLCR completed a complaint investigation. A revisit was completed on 3/6/08 and SLCR issued an uncorrected Class II notice of noncompliance. A second revisit was completed on 4/21/08 and the facility was issued a Class I in addition to uncorrected and new Class II deficiencies. CLASS I: Facility staff failed to initiate CPR on one resident after staff assed (sic) the resident was unresponsive and without a pulse. Staff did not know the resident’s code status as the information was not documented in the resident’s medical records. Interviews with the director of nursing, office manager and the resident’s physician revealed staff should initiate CPR on a resident in cardiac or respiratory arrest if they did not know the resident’s code status. Resident #1 expired. UNCORRECTED CLASS II: The facility did not ensure medications were provided in a safe manner and as ordered by the physician for six residents. Staff also failed to administer and document whether medications were administered according to physician orders. The facility census was 62 residents. | ||
| Facility:
Eldercare RCF
Sedalia, MO 12-Bed Residential Care Facility Date of Notice: May 2008 |
Owner: Joyce A.
Reeves
Operator: Eldercare LLC Registered Agent: Al Kroeger |
Legal Action: Uncorrected Class II Notice of Compliance |
| Description: SLCR staff completed an annual inspection on 2/20/2008 and cited violations. A revisit was completed on 4/18/2008. The facility failed to ensure that all emergency lights would operate for one and one-half hours. The facility census was 11 residents. | ||
| Facility:
Ridgeway Residential Care
Sullivan, MO 20-Bed Assisted Living Facility Date of Notice: May 2008 |
Owner: Turner,
Deborah J.
Operator: Same Registered Agent: Not Listed |
Legal Action: Uncorrected Class II Notice of Noncompliance |
| Description: The facility failed to develop an Individual Service Plan (ISP) to inform staff of the resident’s needs and preferences as required for one resident (Resident #1) recently admitted to the facility. | ||
| Facility:
Columbia Manor Care Center
Columbia, MO 52-Bed Skilled Nursing Facility Date of Notice: June 2008 |
Owner: Columbia
Manor, Inc.
Operator: Same Registered Agent: Hal F. Juckett |
Legal Action: Uncorrected Class II Notice of Noncompliance |
| Description: A complaint investigation was completed on 3/24/08. The facility was not in substantial compliance with participation requirements. A revisit was completed on 5/15/08. The facility failed to ensure services provided or arranged by the facility meet professional standards of practice. Facility staff failed to document administration of treatments as ordered by the physician for three residents. | ||
| Facility:
Jefferson Lodge
Fulton, MO 94-Bed Residential Care Facility Date of Notice: June 2008 |
Owner: Rescare
of Missouri, Inc.
Operator: Same Registered Agent: Eric F. Fink Jr. |
Legal Action: Uncorrected Class II Notice of Noncompliance |
| Description: The facility staff failed to administer two residents’ (Residents #3 and #4) insulin (to treat elevated blood sugar levels) per their physician orders; staff failed to administer one resident’s (Resident #12) medications as directed by his/her physician; staff failed to notify one resident’s (Resident #13) physician of the resident refusing his/her medication for at least three months. The facility failed to ensure one resident (Resident #3) self-administered the correct amount of insulin (to treat elevated blood sugar levels) leading to an episode of hypoglycemia (low blood sugar) and unresponsiveness requiring assistance from Emergency Medical Services (EMS); and failed to ensure qualified staff administered breathing treatments for one resident (Resident #4). | ||
| Facility:
Villa Marie Skilled NSG Facility
Jefferson City, MO 65109 120-Bed Skilled Nursing Facility Date of Notice: July 2008 |
Owner: Liermann
Family Co., LLC
Operator: Eldercare of Mid-Missouri, Inc. Registered Agent: Carl C. Lang |
Legal Action: Uncorrected Class II Notice of Noncompliance |
| Description: The facility failed to ensure a staff person who transported a resident in the facility bus properly secured one resident’s wheelchair. During transport, the resident’s wheelchair tipped over and the resident received a broken collar bone. | ||
| Facility:
Autumn Meadows
Linn, MO 132-Bed Skilled Nursing Facility Date of Notice: July 2008 |
Owner: Piedra,
Enrique & Cheribeth
Operator: Kindred Care, LLC Registered Agent: RayAnne Stubberg |
Legal Action: Class I Notice of Noncompliance |
| Description: The facility failed to ensure staff provided care in accordance with one resident’s wishes for cardiopulmonary resuscitation (CPR) in the event of a cardiac or respiratory arrest. Emergency medical staff (EMS) reported the resident did not have a pulse and only had agonal (related to death) respirations upon arrival at the facility and staff were not performing CPR. EMS staff started CPR, transported the resident to the emergency room where the resident was pronounced dead. The facility census was 84 residents. | ||
| Facility:
Frene Valley Health Center
Hermann, MO 118-Bed Skilled Nursing Facility Date of Notice: July 2008 |
Owner: Frene
Valley Corporation
Operator: Lloyd Healthcare Management Systems, Inc. Registered Agent: Husch Registered Agent, Inc. |
Legal Action: Uncorrected Class II Notice of Noncompliance |
| Description: At the revisit on 07/16/2008, the facility licensed nursing staff failed to assess one resident for side effects of the medication Coumadin (a blood thinning medication) resulting in hospitalization for blood transfusions. The facility census was 82 residents. | ||
| Facility:
Jefferson Lodge
Fulton, MO 94-Bed Residential Care Facility Date of Notice: August 2008 |
Owner: Rescare
of Missouri, Inc.
Operator: Same Registered Agent: Eric F. Fink Jr. |
Legal Action: Uncorrected Class II Notice of Noncompliance |
| Description: At the revisit on 07/21/2008, the facility failed to correct the violation related to a safe and effective system of medication control and use. The facility failed to reorder medications for five residents from the pharmacy in a timely manner. | ||
| Facility:
Jefferson Lodge
Fulton, MO 94-Bed Residential Care Facility Date of Notice: September 2008 |
Owner: Rescare of Missouri,
Inc.
Operator: Same Registered Agent: Eric F. Fink Jr. |
Legal Action: Uncorrected Class II Notice of Noncompliance |
| Description: At the revisit on 07/21/2008, the facility failed to correct the violation related to a safe and effective system of medication control and use. The facility failed to reorder medications for five residents from the pharmacy in a timely manner. | ||
| Facility: Autumn
Meadows
Linn, MO 132-Bed Skilled Nursing Facility Date of Notice: September 2008 |
Owner: Piedra, Enrique
& Cheribeth
Operator: Kindered Care, LLC Registered Agent: RayAnn Strubberg |
Legal Action: Class I Notice of Noncompliance |
| Description: A complaint investigation was completed on 9/17/08. The facility failed to ensure each resident received personal attention and nursing care in accordance with his/her condition and consistent with current acceptable nursing practice. Upon admission on 08/02/2008, the facility had knowledge that the resident was an insulin dependent diabetic, required blood sugar monitoring four times a day, and took Digoxin (the proper dosage is determined through regular monitoring of blood levels). The licensed nurse did not verify or clarify admission orders and did not obtain orders for blood sugar monitoring, insulin administration, or laboratory tests for Digoxin levels. From 08/04/2008 to 08/20/2008, the resident did not receive any insulin injections, staff did not monitor blood sugars and no laboratory tests were done for Digoxin levels. On 08/20/2008, staff discovered the errors and notified the physician for orders. The resident’s blood sugar was “high” and staff notified the physician who ordered the resident be sent to the hospital for evaluation and treatment. In the emergency room, laboratory testing was done. The emergency room physician noted diagnosis of uncontrolled diabetes, Digitalis (Digoxin) toxicity with vomiting and the resident was hospitalized for treatment. | ||
| Facility:
Warrenton Manor
Warrenton, MO 120-Bed Skilled Nursing Facility Date of Notice: October 2008 |
Owner: Fellowship Nursing
Homes, Inc.
Operator: N & R of Warrenton, Inc. Registered Agent: Charlotte Stutts |
Legal Action: Class I Notice of Noncompliance |
| Description: During the annual licensure inspection, the facility failed to comply with Fire Safety Requirements. Two of two exit doors located in the Special Care Unit and equipped with delayed egress, did not release when the fire alarm was activated. Sixteen dependant residents lived in the Special Care Unit including one resident that did not ambulate and was totally dependent on staff for all activity of daily living needs. | ||
| Facility:
Eldercare RCF
Sedalia, MO 12-Bed Residential Care Facility Date of Notice: October 2008 |
Owner: Reeves, Joyce
A.
Operator: Eldercare LLC Registered Agent: Al Kroeger |
Legal Action: Uncorrected Class II Notice of Noncompliance |
| Description: At the third revisit on 10/01/2008, the facility was not in substantial compliance in the following areas: Physical Plant requirements – The Owner failed to maintain residents furniture and facility equipment including chairs, couches, mattresses, lighting fixtures, door knobs, toilets and one of one stove/oven clean and in good condition. The Owner failed to provide daily cleaning and routine housekeeping services necessary to maintain resident rooms in a safe, clean and sanitary manner. Resident Rights requirements - The Owner failed to ensure resident (sic) were treated in a manner that maintained or enhanced their dignity. | ||
| Facility: Harmony
Gardens
Warrensburg, MO 64-Bed Assisted Living Facility Date of Notice: December 2008 |
Owner: Harmony Gardens
Residential LLC
Operator: Same Registered Agent: Husch Registered Agent, Inc. |
Legal Action: Class I Notice of Noncompliance |
| Description: Facility staff failed to ensure one resident’s (Resident #1) personal care needs were met as identified in the resident’s Individualized Service Plan (ISP), and the resident sustained a facility acquired pressure ulcer (localized injury to the skin and/or underlying tissue, as a result of pressure in combination with shear and/or friction). Resident #1 had some urinary incontinence, wore briefs, and staff were to check on the resident every “couple of hours” to assist the resident with toileting. The resident also needed staff assistance with peri-care. On 10/27/08, the resident had a change in his/her physical condition, and the resident was unable to ambulate with a walker, unable to transfer him/herself, and unable to perform activities of daily living. The resident sat in his/her recliner for approximately three days, which resulted in advanced skin deterioration to the resident’s coccyx (tail bone). Facility staff stated the pressure ulcer was open when seen at 3:00 p.m. on 10/30/08. The resident reported he/she had pain in his/her bottom for at least three days. Upon admission to the hospital on 10/30/08, the resident’s pressure ulcer measured 6 centimeters (cm) in length, 3.5 cm in width, 3 cm in depth, and the pressure ulcer had redness. The facility census was 36. | ||
| Facility:
Eldercare RCF
Sedalia, MO 12-Bed Residential Care Facility Date of Notice: December 2008 |
Owner: Reeves, Joyce
A.
Operator: Eldercare, LLC Registered Agent: Alexander Kroeger |
Legal Action: Uncorrected Class II Notice of Noncompliance |
| Description: At the revisit on 12/03/2008, the facility failed to correct violations in the following areas: Fire Safety Standards: The facility failed to remove accumulated trash and combustible debris from the premises to prevent fire hazards and a public health nuisance. Physical Plant Requirements: The facility failed to maintain resident furniture and light fixtures in good condition and repair and failed to ensure residents mattresses were clean and in good repair. Dietary Requirements: The facility failed to ensure a qualified individual reviewed and documented the diet, food preparation and service for one resident ordered to receive a modified diet. General Sanitation Requirements: The facility failed to use effective measures to minimize the presence of roaches, rodents and other insects throughout the facility including in resident rooms and in the kitchen. Sanitation Requirements for Food Service: The facility failed to protect food from potential contamination while being stored and repaired. | ||
|
KANSAS CITY REGION | |||
| Facility: Myers
Nursing & Convalescent Center
Kansas City, MO 64127 84-Bed Intermediate Care
Facility Date of Notice: January 2008 |
Owner: Not Listed
Operator: Myers Nursing Home, Inc. Registered Agent: Gary Marvine |
Legal Action: Class I Notice of Noncompliance | |
| Description: The facility failed to assess a resident with a declining health status, to administer physician ordered medication to help relieve the resident’s symptoms of nausea and vomiting, to follow physician’s orders to check the resident’s blood glucose levels and administer scheduled and sliding scale insulin, to contact the resident’s physician to advise him/her of the resident’s change of condition, and failed to administer cardiopulmonary resuscitation (basic life support consisting of opening the airway, providing artificial breathing, and assisting circulation by way of opening the airway, providing artificial breathing, and assisting circulation by way of chest compressions used to sustain life until more advanced treatments can restore spontaneous cardiac, pulmonary, and brain function), for one of 16 sampled residents (Resident #14) who was a full code status per physician’s orders and who expired at the facility on the morning of 12/707. | |||
| Facility:
Greens at Creekside
Kansas City, MO 180-Bed Skilled Nursing Facility Date of Notice: January 2008 |
Owner:
Chaudhary International, LLC
Operator: Fayjay, Inc. Registered Agent: Stephanie G. Hazelton |
Legal Action: Uncorrected Class II Notice of Noncompliance | |
| Description: A licensure inspection was completed on 9/19/07. The facility was not in compliance with participation requirements. Revisits were completed on 11/8/07 and 1/10/08. The facility is not in substantial compliance with participation requirements. The facility failed to: Follow the facility’s policy and the care plan regarding care of one resident with a feeding tube, failed to obtain a physician’s order before applying an antibiotic ointment to the feeding tube site for one resident. Follow physician orders regarding care and treatment of indwelling urinary catheters. In addition, the facility failed to ensure all licensed nursing staff showed competency when changing a resident’s indwelling catheter. Follow the facility’s fall policy for assessing and monitoring a resident’s condition after two residents fell. | |||
| Facility:
ABC Health Center
Harrisonville, MO 60-Bed Skilled Nursing Facility Date of Notice: January 2008 |
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 staff failed to provide adequate supervision, intervention, and care for two residents (Residents #1 and #2) after a Certified Nurse’s Assistant (CNA) witnessed a possible sexual assault of Resident #1 by Resident #2 and failed to provide appropriate protective oversight measures and interventions to prevent the occurrence of two additional incidents within the next two hours after the first incident occurred among the same two residents (Residents #1 and #2). Staff also failed to timely contact each resident’s physician and responsible party after the possible sexual assault occurred, failed to obtain medical attention for Resident #1 after the possible sexual assault occurred, failed to follow nursing standards of care when a nurse conducted a digital rectal exam without a physician’s order and potentially destroyed sexual assault evidence for one resident (Resident #1), and inaccurate documentations occurred of the facility’s incident report by stating the physician was contacted at 9:00 a.m. when the physician was actually contacted at 11:00 a.m. on 1/9/08 and the incident report was dated as being completed on 1/8/08 when it was actually completed on 1/9/08, and staff failed to document the incidents per nursing standards and facility policy for two residents (Residents #1 and #2) of six sampled residents. | |||
| Facility:
Carondelet Manor
Kansas City, MO 162-Bed Skilled Nursing Facility Date of Notice: February 2008 |
Owner:
Carondelet Health
Operator: Carondelet Long Term Care Facilities, Inc. Registered Agent: Brent Lagergren |
Legal Action: Uncorrected Class II Notice of Noncompliance | |
| Description: A survey was completed on 12/06/07. The facility was not in substantial compliance with participation requirements. A revisit was completed on 1/30/08. The facility failed to provide or arrange services to meet professional standards of quality. Staff failed to accurately document two residents code status, document the effectiveness of one resident’s pain medication and verify medication and treatments were administered as ordered by the physician. In addition the facility failed to store, prepare and serve food under sanitary conditions. The facility staff failed to remove their gloves and wash their hands after contact with contaminated surfaces and using their bare hands to handle food items. Also staff failed to ensure dietary staff wore bread restraints to prevent contamination of food. | |||
| Facility:
Myers Nursing and Convalescent Center
Kansas City, MO 84-Bed Skilled Nursing Facility Date of Notice: March 2008 |
Owner: G L
Enterprises, Inc.
Operator: Myers Nursing Home, Inc. Registered Agent: Gary L. Marvine |
Legal Action: Uncorrected Class II Notice of Noncompliance | |
| Description: The facility staff failed to follow the physician’s order to provide physical therapy for one resident (Resident #5); failed to follow the physician’s order for administering insulin for two residents (Resident #1 and Resident #20); failed to ensure that licensed staff applied a medication; and failed to have a policy on when to leave medications at the resident’s bedside for one resident (Resident #9) out of 11 sampled residents. The facility staff failed to ensure two residents (Resident #1 and Resident #9) out of 11 samples residents were provided with appropriate incontinence care. The facility staff failed to administer insulin as prescribed by the physician resulting in elevated blood sugar levels that resulted in a significant medication error which jeopardized the health and safety of two sampled residents (Resident #1 and Resident #20) out of 11 sampled residents. The facility staff failed to provide sanitary storage for oxygen concentrator tubing and a C-PAP machine (a machine that provides continuous positive airway pressure that assists in keeping the airway open) face mask for one sampled resident (Resident #6) who uses a C-PAP machine and oxygen concentrator; failed to have a policy and a care plan instructing staff on how to care for a resident with an infectious disease that affects the liver, a history of Methicillin Resistant Staphylococcus Aureus (MRSA, a strain of infectious bacteria that is resistant to the action of methicillin, penicillinase-resistant antibiotic) with open bleeding sores to his/her arms, legs, and abdomen, and a dialysis shunt (an arteriovenous shunt created for use during renal dialysis) that sometimes bleeds after dialysis for one sampled resident (Resident #20); and failed to follow their policy to wear gloves when administering insulin for one sampled resident (Resident #125) out of 11 sampled residents. | |||
| Facility:
Hidden Lake Care Center
Raytown, MO 112-Bed Skilled Nursing Facility Date of Notice: March 2008 |
Owner:
Stratford Health Care Group, Inc.
Operator: Same Registered Agent: Kenneth R. Blom |
Legal Action: Uncorrected Class II Notice of Noncompliance | |
| Description: The facility failed to ensure a foley catheter bag remained off the floor, to obtain a medical diagnosis for the use of a foley catheter, to assess a strong urine odor in the resident’s room, and to assess and document urinary output for a resident with a history of urinary tract infections. | |||
| Facility:
Holmesdale Healthcare and Rehab Center
Kansas City, MO 100-Bed Skilled Nursing Facility Date of Notice: March 2008 |
Owner: Not
Listed
Operator: Holmesdale Healthcare and Rehab Center, LLC Registered Agent: National Registered Agents, Inc. |
Legal Action:
Class I Notice of Noncompliance In a letter from DHSS: On 2/29/2008, SLCR staff completed a revisit at the facility and determined that the Class I deficiency could be lowered to a Class II. | |
| Description: The facility failed to appropriately monitor, assess and respond to a resident with a potential for choking in the dining room, administer the Heimlich Maneuver (a technique of back blows, abdominal thrust, and chest thrust used to remove a foreign body, such as food from the trachea, when it is preventing air flow to and from the lungs), suction, or provide adequate oxygen in an unwitnessed emergency situation resulting in the death of one resident. | |||
| Facility:
Ashton Court Care & Rehab Center
Liberty, MO 140-Bed Skilled Nursing Facility Date of Notice; March 2008 |
Owner: Diamond
Senior Living, LLC
Operator: Ashton Court Healthcare, LLC Registered Agent: CSC—Lawyers Incorporating Service |
Legal Action: Uncorrected Class II Notice of Noncompliance | |
| Description: A survey was completed on 11/07/07. The facility was not in substantial compliance with participation requirements. Revisits were completed on 1/04/08 and 3/17/08. The facility failed to ensure compliance with all fire safety code requirements. The facility staff failed to equip their emergency generator with a remote annunciator panel (an electrical panel connected to the emergency generator that allows staff to monitor the status of the generator) that met the requirements of the National Fire Protection Association. The annunciator panel did not have all required monitoring indicators to allow staff to monitor the generator’s status. | |||
| Facility:
Cedars of Liberty, Inc.
Liberty, MO 206-Bed Residential Care Facility Date of Notice: March 2008 |
Owner: Cedars
of Liberty, Inc.
Operator: Same Registered Agent: James L. Webb |
Legal Action:
Uncorrected Class I Notice of Noncompliance In a letter from DHSS: On 3/25/2008, SLCR staff completed a revisit at the facility and determined that the Class I deficiency could be lowered to a Class II.
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| Description: SLCR Staff completed a complaint investigation on 1/31/08 and cited the facility at that time with a Class I violation. A revisit was completed 2/21/08 and the facility had not taken steps to correct the violation. The facility failed to ensure staff gave insulin-dependent diabetics food within the timeframe specified by the manufacturers of the insulin to prevent the potential for serious or life threatening adverse reactions for three (Residents #2, #3, and #4) of 18 insulin dependent diabetics. The facility census was 25. | |||
| Facility:
Rehabilitation Center of Raymore
Raymore, MO 128-Bed Skilled Nursing Facility Date of Notice: March 2008 |
Owner: East
Sunrise Properties LLC
Operator: Raymore Care Center LLC Registered Agent: Raymore Healthcare, Inc. |
Legal Action: Uncorrected Class II Notice of Noncompliance | |
| Description: The facility failed to obtain a medical symptom for the use of a lap buddy for one resident. The facility failed to ensure staff transferred one resident in a safe manner and according to his/her care plan; failed to maintain one resident’s use bathing/shower room on the 700 hall free of accident hazards. The facility also failed to ensure all staff when on duty was awake, alert and able to perform their duties. The facility failed to have a system in place according to facility policy for the tracking of the administration or refusal of the influenza and pneumonia vaccines and test; and failed to provide residents with education to the benefits for receiving or refusing the vaccinations. The facility staff failed to follow accepted infection control practices by not cleaning a Continuous Positive Airway Pressure (CPAP) machine, tubing, or mask for one resident. The facility staff failed to track the tuberculosis testing. | |||
| Facility:
The Bishop Spencer Place, Inc.
Kansas City, MO 60-Bed Skilled Nursing Facility Date of Notice: April 2008 |
Owner: The
Bishop Spencer Place, Inc.
Operator: Same Registered Agent: S&B Corporate Services, Inc. |
Legal Action:
Class I Notice of Noncompliance In a letter from DHSS: On 4/04/2008, SLCR staff completed a revisit at the facility and determined that the Class I deficiency could be lowered to a Class II.
| |
| Description: The facility staff failed to monitor, assess, and seek medical treatment for one of four sampled residents (Resident #1) with a significant change of condition. The resident, who had a colonoscopy (examination of the upper portion of the rectum with an elongated speculum) with a polypectomy (surgical removal or a tumor commonly found in the rectum) on 3/14/08, began bleeding from the rectum on 3/18/08. On 3/18/08 at 3:00 a.m., the resident had a “large amount of watery, tarry (black) stools,” and at 11:20 a.m., the resident had a “dark, black, red-colored” bowel movement. The facility staff did not inform the resident’s physician of the resident’s rectal bleeding. On 3/18/08, the facility discharged the resident to family members who took the resident to another facility, approximately six hours away, by private car. The resident continued to have significant rectal bleeding during transport to and upon admission to the new facility which was the hospital’s post-acute unit, and was directly admitted to the hospital’s Intensive Care Unit (ICU) due to gastrointestinal (GI) bleeding. | |||
| Facility:
Holmesdale Healthcare & Rehab Center
Kansas City, MO 100-Bed Skilled Nursing Facility Date of Notice: April 2008 |
Owner:
Holmesdale Properties, LLC
Operator: Holmesdale Healthcare and Rehabilitation Center, LLC Registered Agent: National Registered Agents, Inc. |
Legal Action: Class I Notice of Noncompliance | |
| Description: The facility staff failed to appropriately
assess two residents at risk for developing pressure ulcers, allowing the
residents to develop Stage IV (a full thickness skin loss with extensive
destruction, tissue necrosis (death), or damage to muscle, bone, or
supporting structures such as the tendon or joint capsule, undermining
(having overhanging margins caused by bacterial infection) and sinus
tracts (a narrow opening or passageway underneath the skin that can extend
in any direction through soft tissue and results in dead space with
potential for abscess formation also may be associated with this staged
ulcer) pressure ulcers. Failed to develop a plan of care specific to the
Stage IV pressure ulcers to include approaches toward wound resolution;
failed to assess a resident’s complaints of pain and discomfort during
wound care, to follow the care plan directives to administer pain
medication prior to initiating treatment, to administer pain medication
when a resident was complaining of pain and discomfort during wound care,
to follow infection control measures related to hand washing and changing
gloves to prevent cross-contamination during wound care, to ensure the
topical medication was appropriately applied to the wound bed, and to
ensure a physician’s order was followed related to keeping the wound
covered with a dressing preventing contamination of the wound by a yeast
infection in close proximity to the wound resulting in the hospitalization
for treatment of the wound for one resident (Resident #20). Failed to
adequately assess a resident’s skin on readmission to the facility, during
bathing the resident, during weekly skin assessments and while providing
activities of daily living in order to identify a wound to the resident’s
right heel in a timely manner in order to begin treatment of the wound, to
reassess the wound in a timely manner to ensure the treatment to the right
heel wound was appropriate and effective and to prevent the spread of
infection from the right heel wound to the right heel bone resulting in
surgery to the resident’s right heel for one resident (Resident #4) of 13
sampled residents. Uncorrected Class II Notice of Noncompliance: The facility staff failed to ensure one resident with a Foley catheter (a tube inserted into the urethra and into the bladder to drain urine from the body), received appropriate incontinent care, failed to ensure staff used appropriate hand washing techniques to prevent cross-contamination while providing incontinence care, and failed to follow facility policy regarding catheter care for one resident (Resident #20) out of thirteen sampled residents. The facility staff failed to maintain infection control practices by failing to keep the oxygen tube of one resident off of the floor and changing the tube after it was on the floor (Resident #9), failing to keep one resident’s catheter privacy bag and tube from dragging on the floor and failing to follow infection control practices during pericare (Resident #20), failing to follow facility policy and failing to ensure staff used appropriate technique including glove use and hand washing while providing care to one resident with a feeding tube (Resident #7) out of thirteen sampled residents. The facility failed to use an Underwriters’ Laboratory (UL) (a nonprofit organization which conducts safety and quality tests on a broad range of products, provides a full spectrum of conformity and quality assessment services to manufacturers and other organizations, offers educational materials to consumers, and works to strengthen safety systems around the world) approved fire calk material (DAP Fireblock Foam, a material which is only for use in residential construction and not for use in commercial in fire rated walls such as the ones present in nursing facilities) to seal gaps and penetrations within the smoke barriers in the attic areas over resident room 409 and resident room 106, and failed to completely seal all smoke barrier penetrations potentially affecting 34 residents residing in those halls. The facility failed to obtain backup sidewall sprinkler heads to store in the spare sprinkler box. | |||
| Facility:
Beautiful Savior Home
Belton, MO 126-Bed Skilled Nursing Facility Date of Notice: April 2008 |
Owner:
Beautiful Savior Home
Operator: Same Registered Agent: A. Glenn Sowders, Jr. |
Legal Action:
Uncorrected Class II Notice of Noncompliance In a letter from DHSS: On 3/31/2008, SLCR staff completed a revisit at the facility and determined that the Class I deficiency could be lowered to a Class II.
| |
| Description: The facility staff failed to adequately assess,
identify the qualified medical symptom for which restraints are necessary
to treat, develop and/or update the plan of care, and provide ongoing
assessments to ensure the least restrictive and most appropriate restraint
devices are used for five of 15 sampled residents (Residents #9, #10, #18,
#25, and #27). Further, the facility staff failed to obtain a physician’s
order for a lap buddy restraint (a soft notched laptop cushion that fits
snugly between person and wheelchair frame) for two sampled residents
(Residents #10 and #18) that contained duration of the restraint,
frequency of the restraint, when to remove the restraint, and the medical
symptom for the restraint; the facility staff failed to obtain a
physician’s order for side rail restraints for four sampled residents
(Residents #9, #10, #25, and #27); and the facility staff failed to obtain
a physician’s order for a Velcro wheelchair lap tray (a hard plastic tray
that sits on top of the wheelchair arms and fastens around the wheelchair
handles) for one sampled resident (Resident #25).
The facility staff failed to accommodate the individual needs of two of 15 sampled residents (Residents #25 and #31). Facility staff placed Resident #25’s food and fluids out of the resident’s reach at the dining room table and did not address in the resident’s care plan for staff not to remove the resident’s lap tray during meals per the resident’s family request and also, per staff interview the resident with use of his/her lap tray, was able to lift his/her glass and drink for himself/herself. Facility staff failed to monitor Resident 31’s edema and provide additional interventions when his/her physician ordered for the resident to wear TED hose (compression stockings used to ensure optimum blood flow and reduce swelling in the resident’s ankles and legs), which did not fit properly. The facility staff failed to provide assistance devices to prevent accidents for two of 15 sampled residents (Residents #15 and #18) and failed to ensure the residents’ environment remains free of accident hazards related to an unlocked, unmanned treatment cart left in a resident use area and unsafe storage of one electrical radio. The facility staff failed to utilize a body alarm for Resident #18 who had a history of falls and failed to follow the written care plan for provision of a body alarm for Resident #15, who also had a history of falls. Further, the facility staff left a (sic) unlocked, unmanned treatment cart after use on the 100 residence hall, potentially affecting all facility residents; and facility staff stored one electrical radio in an unsafe manner above the water fountain across from the Station II Nurses’ Station. The facility staff failed to complete a Tuberculosis (TB) skin test upon admission for one sampled resident (Resident #30) of 15 sampled residents. The facility failed to ensure the 500 hall (resident rooms 501-510) was free of one obstruction (a mechanical lift) that staff did not use, and stored in the corridor for more than thirty minutes, affecting one of four exits from the Station II Residents’ halls (25 residents residing on the 300 hall; 19 residents residing on the 400 hall; and 14 residents residing on the 500 hall) in case of an emergency exit down the 500 hall. | |||
| Facility:
Johnson County Care Center
Warrensburg, MO 87-Bed Skilled Nursing Facility Date of Notice: April 2008 |
Owner: R M
Properties, Inc.
Operator: Johnson County Care, Inc. Registered Agent: Gary L. Marvine |
Legal Action:
Class I Notice of Noncompliance In a letter from DHSS: On 4/01/2008, SLCR staff completed a revisit at the facility and determined that the Class I deficiency could be lowered to a Class II.
| |
| Description: The facility failed to follow facility policy and procedure to ensure residents are not abused when behavior interventions are implemented by facility staff affecting one resident (Resident #1). Facility staff failed to follow Resident #1’s care plans regarding interventions when he/she becomes resistive or agitated. Two Nurse Assistants (NA) carried the resident out of his/her room as instructed by a charge nurse to make Resident #1 go to dinner after he/she had refused to go to dinner. The facility census was 81 residents. | |||
| Facility:
Plaza Manor
Kansas City, MO 154-Bed Skilled Nursing Facility Date of Notice: May 2008 |
Owner: Plaza
Manor Associates
Operator: Plaza Manor, Inc. Registered Agent: Joseph Tutera |
Legal Action:
Class I Notice of Noncompliance In a letter from DHSS: On 5/14/2008, SLCR staff completed a revisit at the facility and determined that the Class I deficiency could be lowered to a Class II.
| |
| Description: The facility staff failed to adequately assess a resident that displayed respiratory distress, failed to inform the resident’s physician in a timely manner of a change in respiratory status, and failed to provide proper equipment for one resident (Resident #3) that had a tracheostomy. The facility staff failed to provide one resident (Resident #4), who had a facility acquired Stage IV pressure ulcer, with a nurse consultant assessment as ordered by the physician on 04/09/08 until 04/21/08. During the time period of 04/09/08 through 04/21/08, the resident’s pressure ulcer deteriorated and became infected. | |||
| Facility:
Clara Manor Nursing Home
Kansas City, MO 90-Bed Skilled Nursing Facility Date of Notice: June 2008 |
Owner: MM
Properties, Inc.
Operator: Clara Manor Nursing Home, Inc. Registered Agent: Gary L. Marvine |
Legal Action: Uncorrected Class II Notice of Noncompliance | |
| Description: The facility failed to prevent one resident (Supplemental Resident #105) from smoking in his/her room, potentially affecting the resident’s roommate and residents in adjacent rooms. | |||
| Facility:
Deaconess Specialty Care Center
Kansas City, MO 116-Bed Skilled Nursing Facility Date of Notice: June 2008 |
Owner:
Deaconess Long Term Care of Missouri, Inc.
Operator: Same Registered Agent: The Corporation Company |
Legal Action: Uncorrected Class II Notice of Noncompliance | |
| Description: The facility failed to complete their remodeling program and maintain ceiling, floors, and wall surfaces in resident-use areas and nonresident-use areas clean and in good repair, and failed to prevent water leaks which caused damage to areas below the leaks, affecting 24 residents (Residents #4, #7, #11, #106, #111, #129, #130, #131, #133, #134, #135, #136, #137, #138, #139, #140, #141, #142, #143, #144, #145, #146, #148, and #149), the facility kitchen, storage rooms, and central resident-use bathrooms. The facility staff failed to adequately assess and document a new resident admission for a possible elopement risk, failed to follow the facility’s policy on an admission of a resident with a possible elopement risk, failed to develop an initial care plan and implement interventions for the safety and supervision for a newly admitted resident with a possible elopement risk, failed to have phone numbers and addresses of family members and/or significant others the resident could possibly elope to for a resident who eloped from the facility, and the facility did not have phone numbers to call or an address to notify the family that the resident was missing from the facility, and failed to communicate information to the appropriate staff that the resident was pacing, asking the staff to leave with family, and calling his/her family frequently at night for one random resident with signs and symptoms of elopement (Resident #22) out of 11 sampled resident. The facility staff failed to keep food out of a medication refrigerator designated only for the residents’ medications that require to be refrigerated, failed to have a thermometer placed inside the medication refrigerator to ensure the correct temperature is being kept to store medications, failed to keep a daily log of the temperatures to ensure the safety of the medications being stored at the appropriate temperatures, failed to keep the medication refrigerator clean of dirt, debris, and dried fluid, failed to defrost the freezer that had two inches of ice buildup all around the freezer and inside the freezer of the medication refrigerator located in the Three South medication room that could potentially affect all the residents who reside in the locked unit on Three South, and failed to discard expired medication that are stored in the refrigerator located in the medication room on Three South affecting one sampled resident (Resident #13), out of 11 sampled residents. The facility staff failed to notify the local health department for one sampled resident’s (Resident #13) positive Tuberculosis (TB) skin test, failed to have a care plan for the resident with a positive TB skin test, and failed to wear gloves or wash hands between residents while performing Accuchecks (a machine that tests the residents’ blood sugar with a drop of blood from a finger stick) affecting two sampled residents (Resident #114 and #140) and one randomly sampled resident (Resident #201) out of 11 sampled residents. | |||
| Facility:
Oak Grove Nursing & Rehab
Oak Grove, MO 90-Bed Skilled Nursing Facility Date of Notice: June 2008 |
Owner: Grove
Oak-Cal Assoc. LP
Operator: N & R of Oak Grove, LLC Registered Agent: Charlotte Stutts |
Legal Action: Class I Notice of Noncompliance | |
| Description: The facility staff failed to follow the facility policy and the standards of nursing practice for one resident (Resident #1) of five sampled residents when staff failed to appropriately assess, monitor, document, and inform the resident’s physician of the resident’s significant change in condition, and to communicate information to the appropriate staff for continuity of care when the resident alerted staff he/she was experiencing chest pain on 5/29/08 at 6:30 p.m. On 5/30/08 at 3:15 a.m., staff found the resident unresponsive and without pulse or respirations. Staff initiated cardiopulmonary resuscitation (CPR) for the resident. Ambulance personal were called to the facility whom (sic) after completion of a telephone consultation with the local hospital emergency room physician, pronounced the resident had expired at the facility on 5/30/08 at 3:44 a.m. Also, the facility staff failed to assess, monitor, and properly document the resident’s bowel movements, removed impacted stool from the resident without a physician’s order, and failed to inform the resident’s physician when the resident did not have a bowel movement for at least 10 days prior to the resident’s death. | |||
| Facility:
Rosewood Health Center
Independence, MO 300-Bed Skilled Nursing Facility Date of Notice: June 2008 |
Owner:
Resthaven, Inc.
Operator: The Groves Registered Agent: Karen E. Minton |
Legal Action: Uncorrected Class II Notice of Noncompliance | |
| Description: The facility failed to ensure one resident’s (Resident #41) physician’s order was followed and documented for strict I&O (intake and output, the amount of fluids taken into the body versus the amount of fluids expelled by the body), failed to assess the resident’s complaints of pain and discomfort associated with the use of a Foley catheter (a tube inserted through the external body opening into the urinary bladder for the purpose of draining urine), failed to notify the resident’s physician of the resident’s complaints of pain and discomfort and to update the care plan to reflect the resident’s current care needs related to the Foley catheter use and the facility also failed to ensure Foley catheter tubing was kept off the floor to prevent contamination for four residents (Resident #41, #34, #107 and #108) of 18 sampled residents. | |||
| Facility:
Swope Ridge Geriatric Center
Kansas City, MO 240-Bed Skilled Nursing Facility Date of Notice: June 2008 |
Owner: City of
Kansas City
Operator: Care Center of Kansas City Registered Agent: Dorothy Fauntleroy |
Legal Action:
Class I Notice of Noncompliance In a letter from DHSS: On 6/04/2008, SLCR staff completed a revisit at the facility and determined that the Class I deficiency could be lowered to a Class II.
| |
| Description: The facility staff failed to adequately assess and document a new resident admission for a possible elopement risk, follow facility policy on an admission of a resident with an elopement risk, develop an initial care plan and implement interventions for the safety and supervision needs of a resident identified as an elopement risk, and communicate information to the appropriate staff for continuity of care on a resident identified as an elopement risk who had a known history of having eloped from his/her previous home setting resulting in the newly admitted resident’s elopement from the facility on 5/17/08 who went missing for approximately nine hours before being located by community members, also causing him/her to miss his/her dialysis (removal of toxic waste from the bloodstream through a catheter) appointment for one resident (Resident #1); and the facility staff also failed to develop an initial care plan and implement interventions for the safety and supervision needs of two additional residents (Residents #2 and #3) who had been identified as an elopement risk and who had eloped from the facility and had failed to communicate this information to appropriate staff, and to the residents’ physicians and responsible parties, of three sampled residents. | |||
| Facility:
Cedar Valley Health Center
Raytown, MO 154-Bed Skilled Nursing Facility Date of Notice: July 2008 |
Owner: Missouri
Regency Assoc., LLC
Operator: Deaconess Long Term Care of Missouri, Inc. Registered Agent: The Corporation Company |
Legal Action: Uncorrected Class II Notice of Noncompliance | |
| Description: The facility failed to maintain water at comfortable temperatures between 105 degrees Fahrenheit (oF) and 120oF and warm enough for the residents to receive baths and resident care affecting residents residing in five halls (100 hall, 200 hall, 300 hall, 600 hall and 800 hall), 11 resident rooms occupied by 12 residents (Resident #6, #108, #110, #111, #112, #113, #114, #115, #116, #117, #118, and #119) and one central shower room; and ensure floors and doors are maintained clean and in good repair in seven resident rooms affecting eight residents (Resident #1, #3, #111, #112, #113, #114, #115, and #116). The facility staff failed to provide proper incontinence care and did not have a care plan to instruct staff on how to care for the resident’s incontinence problem for one resident (Resident #7) out of 13 sampled residents. The facility staff failed to provide proper catheter care to one sampled resident with a suprapubic catheter (a tube that permits direct urinary drainage from the bladder through the lower abdominal wall, from a surgically fashioned opening), failed to have a comprehensive care plan developed and filed in the resident’s medical record for one sampled resident with a suprapubic catheter, and failed to have an admission Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by facility staff, completed and filed in the resident’s medical record after the resident was admitted to the facility on 6/3/08 for one sampled resident (Resident #25); and failed to provide proper Foley catheter (a tube inserted inside the urethra, an opening to the bladder, to drain the urine) care by preventing the catheter tubing from touching the floor and being dragged on the floor from the resident’s room to the dining room for one sampled resident (Resident #24) with an urinary tract infection (UTI) that is being treated with an antibiotic, out of 13 sampled residents. The facility failed to maintain safe water temperatures at all resident-use water fixtures of below 120 degrees Fahrenheit (oF), affecting five resident rooms and five residents (Residents #120, #23, #121, #7, and #109) residing on the north unit 700 hall and 500 hall. The facility staff failed to wash their hands and change their gloves appropriately when providing incontinence care to two residents (Resident #21 and #25) out of 13 sampled residents. The facility failed to provide functioning exhaust ventilation units to provide negative airflow in 12 resident-use bathrooms affecting 14 residents. | |||
| Facility:
Park Place Care Center
Raytown, MO 120-Bed Skilled Nursing Facility Date of Notice: July 2008 |
Owner: William
Morrion Trust
Operator: Deaconess Long Term Care of Missouri, Inc. Registered Agent: The Corporation Company |
Legal Action:
Class I Notice of Noncompliance In a letter from DHSS: On 7/15/2008, SLCR staff completed a revisit at the facility and determined that the Class I deficiency could be lowered to a Class II.
| |
| Description: Based on observation, interview and record review, the facility failed to maintain a continuous fire alarm system connection to the central alarm monitoring service cutting off immediate contact of the facility’s fire alarm system through the central alarm monitor to the fire department, failed to conduct a fire watch (facility staff who inspect all spaces of the facility interior and the exterior for fire on a predetermined schedule; required to be completed when the fire alarm or sprinkler system has malfunctioned) because the facility had no knowledge the fire alarm system was not connected to the central monitor resulting in the fire department not being notified of the fire alarm system activation; and the facility failed to have a policy on what to do if the fire alarm system fails to function appropriately affecting 79 out of 79 residents in the facility. The facility census was 79 residents. | |||
| Facility:
Swope Ridge Geriatric Center
Kansas City, MO 240-Bed Skilled Nursing Facility Date of Notice: July 2008 |
Owner: City of
Kansas City
Operator: Care Center of Kansas City Registered Agent: Dorothy Fauntleroy |
Legal Action: Uncorrected Class II Notice of Noncompliance | |
| Description: The facility staff failed to follow facility policy for residents identified as an elopement risk, develop an initial care plan and implement interventions for the safety and supervision needs of residents identified as an elopement risk, communicate information to the appropriate staff for continuity of care on a resident identified as an elopement risk who have been assessed as being at risk for elopement for three sampled residents (Resident #12, Resident #15, and Resident #19); the facility failed to safely transfer one resident (Resident #101) from his/her wheelchair to his/her bed; failed to ensure the safety of one resident (Resident #105) by allowing the resident to store Lysol cleaner in the corner of his/her room; and failed to provide a safe environment for residents with access to the lower A-level therapy room when staff failed to store two Hydrocollator (machine used to store and prepare hot packs) machines and three whirlpool machines in a secure area, of 21 sampled residents. | |||
| Facility:
Riverside Nursing & Rehab Center
Kansas City, MO 180-Bed Skilled Nursing Facility Date of Notice: July 2008 |
Owner:
Riverside Property Co., LLC
Operator: Riverside Nursing and Rehab Center, LLC Registered Agent: CSC – Lawyers Incorporating Service Co. |
Legal Action:
Class I Notice of Noncompliance In a letter from DHSS: On 7/03/2008, SLCR staff completed a revisit at the facility and determined that the Class I deficiency could be lowered to a Class II.
| |
| Description: The facility failed to assure staff maintained
a system to allow staff to rapidly identify and determine a resident’s
wishes regarding resuscitation measures in the event heartbeat or
breathing ceased. The facility also failed to assure staff provided
cardiopulmonary resuscitation (CPR, an emergency medical procedure for a
victim of cardiac arrest, or in some circumstances, respiratory arrest,
consisting of a combination of chest compressions and lung ventilation)
correctly and in a timely manner. This affected one of 16 sampled
residents (Resident #6). The resident expired on 6/10/08.
The facility failed to: Assure 12 of 13 exit doors equipped with magnetic locks opened immediately upon activation of the fire alarm. Equip eight of 13 doors equipped with magnetic locks with a 15 second delay to allow residents, visitors and staff to exit. Provide proper signage on all doors equipped with a magnetic lock. Assure one door that opened to a fenced-in patio on the Special Care Unit (SCU) was equipped with a “No Exit” sign. Assure staff had access to the key to the padlock placed on the gate outside the temporary care unit (TCU). Assure staff did not wrap a cord for a mini-blind around the panic bar of a designated exit door in the assistive dining room, allowing the door to only open approximately one foot. Assure two doors on the SCU were equipped with an audible alarm when the doors were opened and/or propped open. | |||
| Facility:
Rehabilitation Center of Independence
Independence, MO 130-Bed Skilled Nursing Facility Date of Notice: July 2008 |
Owner: Not
Listed
Operator: The Rehabilitation Center of Independence, LLC Registered Agent: National Registered Agents, INC |
Legal Action: Uncorrected Class II Notice of Noncompliance | |
| Description: Facility staff failed to follow facility policy on Intermittent Feeding via Gastrostomy tube (G-tube) and failed to change the enteral tube feeding bag daily for one sampled resident with a G-tube. Facility staff failed to follow physician’s orders for five (Resident #18, #23, #26, #24 and #25) residents and facility staff failed to follow facility policy on medication, treatment orders and transcription of physician’s orders for three residents (Residents #117, #24, and #25) of out of 14 sampled residents. | |||
| Facility:
Thompson Care Center
Kansas City, MO 80-Bed Residential Care Facility Date of Notice: August 2008 |
Owner: Lara,
Henry & Julia
Operator: Jolet II, Inc. Registered Agent: Lawrence Thompson |
Legal Action:
Class I Notice of Noncompliance In a letter from DHSS: On 8/26/2008, SLCR staff completed a revisit at the facility and determined that the Class I deficiency could be lowered to a Class II.
|
| Description: The facility staff failed to provide twenty-four hour protective oversight to ensure knowledge of all residents’ whereabouts or absence from the facility and the residents’ condition, and failed to follow their policy and procedure for residents signing in/out and staff making rounds, resulting in one resident’s death (Resident #1) out of ten sampled residents. Staff did not confirm Resident #1’s exact whereabouts for approximately 20 hours of time from Sunday, 7/20/08, when staff said the resident was last seen in the facility at approximately 2:00 p.m. until Monday, 7/21/08, when the resident was found deceased by staff inside his/her room between 9:30 and 10:00 a.m. once his/her locked door was opened by staff. The facility failed to protect one resident (Resident #25) of 10 sampled residents from emotional/mental abuse when a staff person attempted to force the resident to get out of bed by pouring a cup of tap water on the foot of the bed causing the resident to become angry and upset. The resident attempted to strike out at the staff person. The facility’s resident advocate stepped between the staff person and the resident to stop the altercation. | ||
| Facility:
Riverside Nursing & Rehab Center
Kansas City, MO 180-Bed Skilled Nursing Facility Date of Notice: August 2008 |
Owner:
Riverside Properties Co., LLC
Operator: Riverside Nursing & Rehab Center, LLC Registered Agent: CSC – Lawyers Incorporating Service Company |
Legal Action: Uncorrected Class II Notice of Noncompliance |
| Description: At the revisit on 08/11/2008, the facility failed to be in substantial compliance because of the following uncorrected violations. The facility failed to ensure a medication error rate of 5% or less. Observation of medication administration by nursing staff revealed the facility had an error rate of 23.4%. Facility staff failed to provide care in a manner to promote and maintain dignity for two residents. Staff failed to ensure one newly admitted resident had clothing that fit properly and covered the resident’s body. Staff failed to treat one resident with dignity during personal care and left the resident exposed when other staff came into the resident’s room. Facility nursing staff failed to transfer three residents with a mechanical lift and one resident with the use of a gait belt in a safe manner to prevent potential injury to the residents. | ||
| Facility:
Hidden Lake Care Center
Raytown, MO 8/11(sic) Bed Skilled Nursing Facility Date of Notice: August 2008 |
Owner:
Stratford Health Care Group, Inc.
Operator: Same Registered Agent: Kenneth R. Blom |
Legal Action: Class I Notice of Noncompliance |
| Description: The facility staff failed to appropriately transfer a resident with the use of a gait belt when staff had assessed and identified the resident required a gait belt for transfer resulting in the resident’s fall on 7/9/08 who sustained a fractured hip and required hospitalization for surgical repair to his/her hip; failed to appropriately assess the resident’s physical condition, strength, and abilities for the resident’s transfer with the sit-to-stand mechanical lift resulting in the resident’s second fall on 8/4/08 when he/she slipped out of the mechanical lift and fell onto the floor when one staff person was assisting the resident to transfer at that time, which required the resident’s transport by ambulance to a local hospital emergency room for further evaluation and treatment resulting in the resident having one seizure during his/her transport to the hospital and the resident had a second seizure upon his/her admission to the hospital; failed to identify and implement adequate interventions and assistive devices to prevent the resident’s reoccurrence (sic) of falls; failed to update/revise interventions in a timely manner when the resident’s condition changed; and failed to communicate to direct care staff specific directions for the most appropriate type of transfer the resident required and what the resident’s strengths and abilities were in order to complete a safe transfer for one resident (Resident #1) of three sampled residents. Also, the facility staff failed to apply a personal body alarm, keep the resident’s bed in a low position, keep the resident’s side rails in the upward position, and to place a mat beside the resident’s bed to prevent falls and injury to one other resident (Resident #2) of three sampled residents. | ||
| Facility:
Deaconess Specialty Care Center
Kansas City, MO 116-Bed Skilled Nursing Facility Date of Notice: August 2008 |
Owner:
Deaconess Long Term Care of Missouri, Inc.
Operator: Same Registered Agent: The Corporation Company |
Legal Action: Uncorrected Class II Notice of Noncompliance |
| Description: Based on record review and interview, the
facility staff failed to ensure one sampled resident (Resident #23) of 10
sampled residents, had an updated care plan with new interventions for
socially and sexually inappropriate behaviors when interventions were not
successful. Facility staff failed to continually assess the resident for
new interventions to ensure the resident’s assessed problem was corrected
and to prevent further incidences of Resident #23 inappropriately and
sexually touching other residents. On 7/06/08, Resident #23 tried to kiss
a facility staff member from behind on the staff member’s neck; on
7/14/08, facility staff witnessed Resident #23 with his/her hands under a
resident’s clothes, touching the resident inappropriately. On 8/02/08,
facility staff observed Resident #23 stroking and squeezing another
resident’s breasts. Facility staff failed to notify the resident’s
physician, the Director of Nursing, or the Administrator of the resident
to resident incidents. The facility census was 81 residents.
Based on observation, record review and interview, facility staff failed to follow their elopement policy for three sampled residents with moderate to high risk for elopements (Resident #24, #27, and #29) out of 10 sampled residents; failed to follow their plan of correction to complete an elopement risk assessment for one resident (Resident #24) who had eloped from a previous facility prior to admission, within eight hours of admission by the admitting nurse (per the plan of correction); failed to develop and update an elopement care plan with interventions for one resident (add Resident #27) that eloped from the facility on 7/13/08, to prevent the potential for further elopements; failed to complete and update an elopement risk assessment before or after the resident eloped from the facility for two sampled resident (Resident #27 and #29); failed to monitor one sampled resident (Resident #29) when the resident was not on the locked unit; failed to follow the facility’s suicide threat policy for two sampled residents with suicidal ideation (Resident #28 and #13) out if 10 sampled residents; failed to sweep two resident’s rooms (Resident #28 and #13) for objects that had the potential to be used for self-harm harm after one resident (Resident #28) made a threat to kill him/herself by hanging him/herself from the sprinkler system and for one sampled resident (Resident #13) who had verbalized suicidal thoughts; failed to update one resident’s (Resident #28) suicidal care plan on 7/10/08, with new interventions after the resident made a suicide threat to kill him/herself by hanging him/herself from the sprinkler system; failed to assess, develop and implement a suicide care plan for one sampled resident (Resident #13) who had verbalized suicidal thoughts and used a brush to scratch him/herself on 7/11/08, and scratched him/herself with a pencil on another incident, and Resident #13 had stated there were voices in his/her head telling him/her to hurt him/herself. The facility census was 81 residents. | ||
| Facility:
Bristol Manor of Odessa
Odessa, MO 12-Bed Residential Care Facility Date of Notice: August 2008 |
Owner: Bristol
Care, Inc.
Operator: Same Registered Agent: David C. Furnell |
Legal Action: Class I Notice of Noncompliance |
| Description: The facility staff failed to ensure one resident (Resident #1) out of seven sampled residents was capable to physically and mentally negotiate the pathway to safety unassisted or with the use of an assistive device, such as a hand walker, within five minutes of being alerted of the need to evacuate the facility. The resident’s mental and physical condition had a major decline when the resident became very confused, was unable to ambulate without physical assistance and use of a hand walker, was incontinent of urine, was resistive to activities of daily living (ADL), primarily bathing, developed behavior issues of fights and cursed at people who are not there, and was identified to have reddened areas under his/her breasts and on his/her buttocks which the staff were unable to meet his/her increased health care needs and were not trained or qualified to provide pressure ulcer treatment and care to the resident. The resident’s reddened areas on his/her buttocks worsened to include multiple scattered small areas of partial thickness skin loss on each buttock that included open areas on his/her inner thighs and buttock(s). On 6/27/08, the resident’s attending physician recommended the resident needed to be admitted to a nursing home. The facility staff continued to care for one resident (Resident #1) out of seven sampled residents whose mental and physical condition had a major decline when the resident became very confused, was unable to ambulate without physical assistance and use of a hand walker, was incontinent of urine, resistive to activities of daily living (ADLs), primarily bathing, developed behavior issues of fights and cursed at people who are not there, and was identified to have reddened areas under his/her breasts and on his/her buttocks which the staff were unable to meet his/her increased health care needs and were not trained or qualified to provide pressure ulcer treatment and care to the resident. The resident’s reddened areas on his/her buttocks worsened to include multiple scattered small areas of partial thickness skin loss on each buttock that included open areas on his/her inner thighs and buttock(s). Further, the staff failed to refer Resident #1 to appropriate outside resources or to discharge the resident from the facility when the resident’s attending physician recommended on 6/27/08 the resident needed to be admitted to a nursing home. | ||
| Facility:
New Mark Care Center
Kansas City, MO 191-Bed Skilled Nursing Facility Date of Notice: August 2008 |
Owner: New Mark
Care Center, Inc.
Operator: Same Registered Agent: Eugene J. Feldhausen |
Legal Action: Uncorrected Class II Notice of Compliance |
| Description: At the revisit on 07/28/2008, the facility failed to correct the following violation: The facility failed to ensure staff provided appropriate indwelling catheter care and infection control procedures to prevent potential for urinary tract infections. The facility census was 180 residents. | ||
| Facility:
Highland Nursing & Rehab Center
Kansas City, MO 162-Bed Skilled Nursing Facility Date of Notice: August 2008 |
Owner: South
Park Partners, LP
Operator: Highland Nursing & Rehabilitation Center, LLC Registered Agent: Michael F. Flanagan |
Legal Action: Uncorrected Class II Notice of Noncompliance |
| Description: The facility failed to maintain one sampled
resident (Resident #12) out of 14 sampled residents and one supplemental
resident (Resident #125) geri-chairs (a soft cushioned reclining
wheelchair that requires someone else to push) in good repair without
exposed wood and rough edges that could be a potential hazard for the
residents’ arms. The facility failed to maintain a safe environment
for residents who use the 400 south shower room as the toilet is not
secured to the floor; for residents in room 218, there are two pieces of
mosaic tile missing on the shower floor; in room 223, one night stand has
a front edge which is uneven and rough to the touch; in room 409, the
night stand door is leaning up against the front of the night stand next
to the resident’s bed; in room 418, the toilet is not secured to the floor
and the over the toilet assistive device (left arm) is positioned under
the toilet paper holder; in room 425, the side chair has exposed metal and
a nail on the back portion of the chair; failed to maintain the floor in
good repair and free of debris and stains in rooms 218, 306, 410, 416, and
418; failed to maintain the closet curtains in good repair in room 418;
failed to maintain the walls in good repair in the 200 North whirlpool
room, the 300 North shower room, in rooms 219 and 417, and in the fourth
floor dining room; failed to maintain the toilet room door in room 418 in
good repair; failed to maintain the over-the-toilet assistive device in
room 418 free of debris; and failed to maintain the third and fourth floor
dining room ceilings free of yellow stains and also, failed to maintain
the fourth floor dining room’s wallpaper from peeling. This deficient
practice has the potential to affect residents in nine resident rooms,
residents using the 200 North whirlpool room, the 300 North shower room,
and the dining rooms on the third and fourth floors. The facility staff failed to date
opened medication for two supplemental residents (Supplemental Resident
#126 and Supplemental Resident #128); failed to destroy expired
medications in the fourth floor nurse’s station medication room; failed to
destroy medications for one discharged resident (Supplemental Resident
#127); and failed to properly label seven suppositories found in the
fourth floor medication room refrigerator. The facility staff failed
to follow acceptable nursing practice and infection control methods by not
cleaning their AccuCheck machine (a machine designed to measure the blood
glucose level in a person’s blood) before and after each use and in
between residents’ blood glucose level checks affecting four randomly
sampled residents (Supplemental Resident #125, Supplemental Resident #129,
Supplemental Resident #130, and Supplemental Resident #131).
The facility failed to maintain the
300-floor pantry ceiling, mop board and wall in good repair. The facility
failed to maintain the corridor walls on the 400, 300, 200 (the floors
with resident rooms), and the 100 floor (entrance to the facility and
contains the kitchen and offices) to be at least 30 minute rated, free
from penetrations, and to be complete from the floor to ceiling. The
facility failed to maintain two sprinkler head fusible links (a
temperature sensitive device of the sprinkler head which when melted at a
predetermined temperature activates a sprinkler), yoke (provides support
to a sprinkler’s deflector and fusible link) and deflector wheel
(disburses water after a sprinkler head is activated) above the dryers in
the laundry room free of dust and debris. The facility failed to maintain the
third and fourth floor corridors free of obstructions that were stored in
the corridor for more than one-half hour, potentially affecting residents
on the center corridor of the third floor and residents on the center and
North corridors of the fourth floor. The facility failed to ensure all ducts which penetrate smoke barriers are equipped with a smoke damper (a device in ductwork designed to block the passage of smoke upon fire alarm system activation) that completely closes upon fire alarm system activation and opens after the system is reset, affecting the north smoke barrier on the 100 floor. This has the potential to affect residents, staff and visitors who utilize the 100 floor for meals and activities. The facility failed to ensure all electrical equipment is maintained according to the National Electrical Code by ensuring the electric wiring certification is up-to-date. | ||
| Facility:
Johnson County Care Center
Warrensburg, MO 87-Bed Skilled Nursing Facility Date of Notice: August 2008 |
Owner: RM
Properties, Inc.
Operator: Johnson County Care, Inc. Registered Agent: Gary Marvine |
Legal Action:
Class I Notice of Noncompliance In a letter from DHSS: On 7/31/2008, SLCR staff completed a revisit at the facility and determined that the Class I deficiency could be lowered to a Class II.
|
| Description: The facility staff failed to provide a safe environment, adequate supervision, and protective oversight to prevent one of six sampled residents (Resident #1) with a history of substance abuse and drug-seeking behaviors from obtaining medications from an unlocked medication cart who then took the antipsychotic medication and became sedated. | ||
| Facility: Park
Place Care Center
Raytown, MO 120-Bed Skilled Nursing Facility Date of Notice: September 2008 |
Owner: William Marron
Trust
Operator: Deaconess Long Term Care of Missouri, Inc. Registered Agent: The Corporation Company |
Legal Action: Uncorrected Class II Notice of Noncompliance |
| Description: The facility staff failed to follow the facility’s policy and a resident’s care plan to safely transfer one sampled resident (Resident #18) when staff lifted the resident under his/her shoulders without the use of a gait belt out of 13 sampled residents. The facility staff failed to ensure medications are given free of error by not following a physician’s order to check a resident’s pulse prior to the administration of Carvedilol (a medication to treat high blood pressure and congestive heart failure, CHF – a condition in which the heart can no longer pump enough blood to the rest of the body) for one sampled resident (Resident #5) and one randomly sampled resident (Resident #103); and by not following a physician’s order to hold Potassium CL (a supplement which closely resembles table salt, commonly used to replenish the body’s sodium levels during diuretic therapy, a medication that increases urinary output) for three days and by not following a physician’s order to administer a medication on an empty stomach, for one resident (Resident #5) of 13 sampled residents. Forty one opportunities were observed and the facility’s medication error rate was 9.8%. | ||
| Facility: New
Mark Care Center
Kansas City, MO 191-Bed Skilled Nursing Facility Date of Notice: September 2008 |
Owner: New Mark Care
Center, Inc.
Operator: Same Registered Agent: Eugene Feldhausen |
Legal Action: Uncorrected Class II Notice of Noncompliance |
| Description: The facility failed to assure staff provided catheter care to prevent the potential for a urinary tract infection for one resident with a suprapubic catheter (a catheter surgically inserted directly into the bladder through the lower abdomen) for one resident. | ||
| Facility: Blue
River Rehab Center
Kansas City, MO 160-Bed Skilled Nursing Facility Date of Notice: September 2008 |
Owner: Chestnut Property
LLC
Operator: Blue River Rehab Center LLC Registered Agents: National Registered Agents, Inc. |
Legal Action: Uncorrected Class II Notice of Noncompliance |
| Description: The facility staff failed to follow a physician’s order to obtain weekly blood pressure for one sampled resident (Resident #25). Failed to follow their pain policy for two sampled residents (Resident #30 and #29); failed to provide a PRN (when needed) pain medication for one sampled resident (Resident #30) that did not have a PRN pain medication for breakthrough pain who experienced pain during wound care, etc. Failed to follow their wound care policy for two sampled residents (Residents #30 and #21) with Stage III pressure ulcers; failed to apply an occlusive dressing for two sampled residents (Residents #30 and #21) with Stage III and Stage IV wounds, etc. Failed to ensure medications were given free of error for the administration of an inhaled medication for two supplemental residents (Resident #101 and #102), and failed to administer a medication according to the physician’s orders for one supplemental resident (Resident #103), etc. Failed to ensure the staff appropriately washed their hands and changed gloves while providing incontinence care for three sampled residents (Resident #19, #26 and #29) and failed to protect a resident from potential infections from staff who did not wash their hands during perineal (genital) care for one sampled resident (Resident #28) of 14 sampled residents. | ||
| Facility: Greens
at Creekside
Kansas City, MO 180-Bed Skilled Nursing Facility Date of Notice: September 2008 |
Owner: Chaudhary
International LLC
Operator: Fayjay, Inc. Registered Agent: Stephanie Hazelton |
Legal Action: Uncorrected Class II Notice of Noncompliance |
| Description:
Based on observation, interview, and record review, the facility
failed to discontinue a previously written physician’s order for a wrist
x-ray and failed to ensure pain medications agreed on the Physician’s
Order Sheet (POS) and the Medication Administration Record (MAR) for one
sampled resident (Resident #2); failed to follow the physician’s order for
medications for one randomly sampled resident (Resident #112); failed to
discontinue medications for one sampled resident (Resident #3) on 9/1/08
as ordered by the physician, when the facility continued to administer
eight does (sic) of the medication to Resident #3 on 9/1/-9/5/08; failed
to make sure the physician’s order sheet was accurate from one month to
another for one sampled resident (Resident #6); failed to measure the
resident’s abdominal girth for one sampled resident with ascites (the
abnormal accumulation of fluid in the peritoneal cavity) associated with
cancer of the liver and who was on the liver transplant list (Resident
#25), failed to follow physician’s orders for a finger splint to the
resident’s fracture ring finger on his/her left hand, failed to update and
implement on how to instruct staff to assist the resident with a splint to
his/her left ring finger, the care plan does not address to monitor the
resident’s left ring finger for pain, swelling, bruising, limited range of
motion, to keep the splint on the left ring finger for one sampled
resident (Resident #1), failed to follow physician’s orders to obtain a
lab draw for hemoglobin (the iron-containing pigment of the red blood
cells that carries oxygen from the lungs to the tissues. A test to see if
the resident is anemic and may require a blood transfusion), and
Hematocrit (the volume of red blood cells packed in a given volume of
blood) for one sampled resident who was anemic (a reduction in the mass of
circulating red blood cells), and failed to follow physician’s orders for
Slow Fe (iron supplement) one tablet daily for one sampled resident who
was anemic (Resident #7); and failed to follow up with the hospital about
discharge and care for one resident who was readmitted to the facility
with a suspected leg fracture (Resident #16) out of 25 sampled residents.
The facility census was 151 residents.
Based on observation, interview, and record review the facility failed to provide one resident (Resident #12) who had verbally abusive behaviors with adequate supervision on the smoking patio; Resident #12 became verbally abusive towards Supplemental Resident #101, and Resident #101 threw a water pitcher cup at Resident #12’s chest. Facility failed to re-assess one resident’s (Resident #4) transfer needs, and failed to update the resident’s care plan after the resident sustained a fractured left clavicle; failed to follow facility policy and procedures for gait belt use for Resident #4; Resident #4, who required total dependence on staff for transfers, was transferred without a gait belt by facility staff. The facility failed to ensure one resident (Resident #8), assessed as at high risk for elopements, had an appropriate assessment to determine the appropriateness for activities outside the facility; facility staff attempted to take Resident #8 to McDonald’s, and once outside the facility the resident refused to get into the staff’s car and ran from staff off facility property; the facility failed to ensure staff communicated with the mental health unit where Resident #8 resided, prior to taking the resident off the unit; and the facility failed to update Resident #8’s care plan for interventions to address the resident’s behaviors after the resident was re-admitted to the facility from the hospital; facility staff also failed to notify Resident #8’s legal guardian that the resident was being transferred to the hospital for an evaluation. The facility failed to adequately monitor one resident (Resident #21), assessed as a high risk for falls; facility staff left Resident #21 on the toilet unattended, and the resident was found by staff crawling on the floor of his/her room; Resident #21 sustained a skin tear to his/hear elbow; failed to keep the medication locked at all times when the cart was not being used by staff, affecting all the residents on the 100 hall; failed to maintain locked medication carts and double locked narcotic boxes for two medication carts, potentially affecting twelve residents who ambulated or propelled themselves in wheelchairs on the 100, 200, 300, 400, and 500 halls. The facility sample was 25 residents. The facility census was 151 residents. | ||
| Facility:
Rosewood Health Center
Independence, MO 300-Bed Skilled Nursing Facility Date of Notice: September 2008 |
Owner: Resthaven,
Inc.
Operator: The Groves Registered Agent: Karen Minton |
Legal Action: Class I Notice of Noncompliance |
| Description: The facility staff failed to provide an ongoing assessment for pain which began on 7/10/08 and failed to communicate adequate information to the attending physician for one sampled resident (Resident #1) out of three sampled residents, who had a history of peripheral vascular disease which resulted in an untimely transfer of the resident to the hospital on 08/04/08 for further evaluation and treatment. Further testing at the hospital showed the resident had partial blockage of the right femoral artery and complete blockage of his/her left femoral artery. The resident required emergency surgery on 08/05/08 to remove the blood clots from his/her lower legs. The resident’s condition worsened and the resident died at the hospital on 08/07/08 from sepsis. | ||
| Facility:
Rehabilitation Center of Independence
Independence, MO 130-Bed Skilled Nursing Facility Date of Notice: October 2008 |
Owner: Not Listed
Operator: The Rehabilitation Center of Independence LLC Registered Agent: National Registered Agents, Inc. |
Legal Action: Uncorrected Class II Notice of Noncompliance |
| Description: The facility failed to ensure one resident (Resident #25) assessed by the facility with moderate pain, and diagnoses of scoliosis (a side-to-side curvature of the spine which may cause pain and discomfort), and general osteoarthritis (a chronic non-inflammatory bone disease that may produce symptoms of deep aching joint pain and joint swelling), was reassessed upon readmission to the facility from the hospital for pain on 09/22/08. The facility failed to ensure the resident received his/her pain medications, as ordered by the resident’s physician, resulting in the resident’s increased pain. The facility also failed to communicate in a timely manner with the resident’s pharmacy, to ensure the resident’s medications were delivered to the facility. The facility failed to ensure the current medication sheet was accurate based on Resident #25’s current physician medication orders. The facility failed to implement and update the care plan for pain and communication to reflect Resident #25’s assessed needs, to ensure the resident’s pain was addressed for one of 13 sampled residents. The facility census was 87 residents. The facility failed to confirm that the physician had knowledge of the resident’s elevated blood pressures on 08/23/08 and 08/24/08 for one resident (Resident #10). Facility nursing staff also failed to document on the Medication Administration Record for prn (as needed) medications, to ensure Resident #10 did receive his/her medications as ordered by the physician to lower his/her blood pressure; facility nursing staff failed to document the effectiveness of the prn medication to ensure the resident’s elevated blood pressure was treated. | ||
| Facility:
Holmesdale Healthcare & Rehab Center
Kansas City, MO 100-Bed Skilled Nursing Facility Date of Notice: October 2008 |
Owner: Holmesdale
Properties, LLC
Operator: Holmesdale Healthcare & Rehab Center, LLC Registered Agent: National Registered Agents, Inc. |
Legal Action: Class I Notice of Noncompliance |
| Description: Based on interview and record review, the facility failed to ensure the facility had staff available who were trained and certified in Cardiopulmonary Resuscitation (CPR) to perform CPR on one resident (Resident #1), when Resident #1 became unresponsive; facility staff failed to perform CPR on Resident #1 promptly after staff became aware the resident was unresponsive. The facility failed to ensure the emergency crash cart in the hall Resident #1 resided was stocked with an Ambu-bag (bag used for artificial breathing), and staff had to go find another crash cart in another hall. After the second emergency crash cart was brought to the resident’s room, facility staff then began to perform CPR. The Certified Nursing Assistant (CNA) who began chest compressions and the Licensed Practical Nurse (LPN) who began artificial breathing had not received current CPR training, and both staff were not certified in CPR. The facility failed to follow their policy and procedures to maintain a properly stocked emergency crash cart, to assure only persons certified in CPR perform CPR, and to require all licensed nursing staff to have a current certification in CPR, potentially effecting (sic) 54 of 72 residents who had orders for full code (requiring CPR if their heart stopped or they stopped breathing.) The facility failed to adequately provide facility staff certified in CPR on duty at all times for eight of eleven sampled residents (Resident #1, #2, #3, #4, #7, #8, #9 and #10), who had heart related diagnoses and were full code status. The facility census was 72 residents. | ||
| Facility:
Grandview Manor Care Center
Grandview, MO 102-Bed Skilled Nursing Facility Date of Notice: October 2008 |
Owner: Grandview Care
Center, Inc.
Operator: Same Registered Agent: Hal Juckette |
Legal Action: Uncorrected Class II Notice of Noncompliance |
| Description: The facility staff failed to identify a medical symptom and failed to complete the necessary assessments for the use of side rails for one resident (Resident #24) of eight sampled residents. The facility staff failed to follow their policy on assessment and cleaning a suprapubic catheter (a tube inserted through the abdominal wall above the pubic bone directly into the urinary bladder for the purpose of removing urine from the body) site for one sampled resident (Resident #21) of ten sampled residents. | ||
| Facility: Greens
at Creekside
Kansas City, MO 180-Bed Skilled Nursing Facility Date of Notice: November 2008 |
Owner: Chaudhry
International, LLC
Operator: Fayjay, Inc. Registered Agent: Stephanie Hazelton |
Legal Action: Uncorrected Class II Notice of Noncompliance |
| Description: The facility failed to follow their policy for investigation of injuries of unknown facility failed to document and investigate bruising of an unknown origin for Resident #26 (sic). The resident had bruising of an unknown origin found by origin for one sampled resident (Resident #26) of 15 sampled residents; the hospital staff on the first day of admission to the hospital. Resident #26 was admitted to the hospital from the facility on 10/25/08. | ||
| Facility:
Wilshire at Lakewood
Lee’s Summit, MO 170-Bed Skilled Nursing Facility Date of Notice: November 2008 |
Owner: Lakewood Properties,
LC
Operator: Lakewood Care Center of Lee’s Summit, LC Registered Agent: Will Markel |
Legal Action: Class I Notice of Noncompliance |
| Description: The facility staff failed to prevent, identify, assess, monitor, and treat skin ulcers on the right hand of one resident; failed to identify, assess, monitor, treat pain, and procure pain medication according to physician orders for the resident; and failed to identify, monitor, treat oral lesions, and provide oral care for the resident. | ||
| Facility:
Woodbine Healthcare & Rehab Center
Gladstone, MO 300-Bed Skilled Nursing Facility Date of Notice: November 2008 |
Owner: Not Listed
Operator: Woodbine HealthCare, LLC Registered Agent: CSC-Lawyers Incorporating Service Co. |
Legal Action: Class I
Notice of Noncompliance In a letter from DHSS: On 11/14/2008, SLCR staff completed a revisit at the facility and determined that the Class I deficiency could be lowered to a Class II.
|
| Description: The facility failed to assure staff assessed one sampled resident (Resident #65) who had a nutritional deficit, for nutritional needs including fluids and failed to monitor the resident’s food and fluid intake. The resident was admitted to the facility on 10/12/08. After four days in the facility the resident lost 4.8% of his/her body weight. In addition, the resident developed diarrhea and staff failed to inform the licensed nurses of the length of time the resident had diarrhea. On 10/23/08, the resident was hospitalized with severe dehydration, fecal impaction and acute renal failure. The facility census was 242. | ||
| Facility: Glennon
Place Nursing Center
Kansas City, MO 120-Bed Skilled Nursing Facility Date of Notice: December 2008 |
Owner: Encare Nursing CTR
PTRS LTD-85
Operator: SA-ENC Glennon Place, LLC Registered Agent: National Corporate Research Ltd. |
Legal Action: Class I
Notice of Noncompliance In a letter from DHSS: On 12/01/2008, SLCR staff completed a revisit at the facility and determined that the Class I deficiency could be lowered to a Class II.
|
| Description: The facility staff failed to prevent the advanced deterioration to eschar tissue (dead tissue) of one resident’s bilateral heels (Resident #13); failed to follow the facility’s “Wound Prevention Standards and Wound and Skin Treatment Guidelines” policy for four residents (Residents #6, #7, #12, and #13); failed to properly assess, stage, and document the pressure ulcers for three residents (Residents #6, #12, and #13); failed to conduct weekly skin assessments as ordered by the physician for four residents (Resident #6, #7, #12 and #13); failed to perform daily treatment to the right ankle as ordered by the physician for one resident (Resident #7); failed to obtain a physician’s order for DuoDerm (flexible dressing that adheres to the skin) to the left buttocks for one resident (Resident #6); failed to follow the physician’s orders for prevention and treatment measures to prevent and promote healing of two residents’ pressure ulcers which included elevating the residents’ heels (Residents #12 and #13), use of waffle boots to keep the resident’s heels off of his/her Geri-chair and mattress surfaces for one resident (Resident #13) and use of heel protectors for one resident (Resident #12); failed to timely obtain an occupational therapy and/or physical therapy consult for appropriate positioning and obtain a pressure relieving mattress to prevent and/or treat the pressure ulcers for one resident (Resident #13); failed to obtain a nutritional consult from the facility’s Registered Dietician consultant for two residents (Residents #6 and #13); failed to notify and keep the physician informed of new pressure ulcers and to obtain new orders when the current pressure ulcer treatment regimen did not improve one resident’s pressure ulcers (Resident #6); failed to notify, keep the physician informed and to obtain appropriate treatment orders when one resident (Resident #13) developed a right heel pressure ulcer; failed to properly communicate to the nursing staff and other appropriate staff (e.g. the Dietary Manager, Registered Dietician, Physical Therapist, and/or Occupational Therapist) the skin care conditions and the necessary care and treatment services required to promote healing of two residents’ pressure ulcers (Residents #13 and #12); failed to notify the responsible party of one resident’s pressure ulcers (Resident #13); failed to update the skin integrity care plan for one resident (Resident #13) and the Braden Scale (a clinically validated tool that allows nurses and other health care providers to reliably score a patient/client’s level of risk for developing pressure ulcers) for one resident (Resident #12) regarding the resident’s current skin condition. | ||
| Facility:
Lutheran Nursing Home
Concordia, MO 113-Bed Skilled Nursing Facility Date of Notice: December 2008 |
Owner: Lutheran Good
Shepherd Home
Operator: The Lutheran Nursing Home Registered Agent: Paul Tebbenkamp |
Legal Action: Uncorrected Class II Notice of Noncompliance |
| Description: At the revisit on 12/02/2008, the facility staff failed to: Release seat belt restraints at meal times as directed in two residents’ care plans and ordered by the physician. Handle one resident’s indwelling urinary catheter in an appropriate manner to prevent a urinary tract infection. | ||
| Facility:
Heartland of Willow Lane
Butler, MO 98-Bed Skilled Nursing Facility Date of Notice: December 2008 |
Owner: HCR Manor Care
Properties, LLC
Operator: Heartland-Willow Lane of Butler MO, LLC Registered Agent: C T Corporation System |
Legal Action: Class I Notice of Noncompliance |
| Description: The facility staff failed to provide adequate supervision to prevent one of four sampled residents (Resident #1) with confusion and wandering behaviors from leaving the building at night on 11/21/08 during cold weather conditions, failed to detect that the resident had left the building unnoticed by staff, and staff reset the exit door alarm at the end of the 300 Hall (where the resident resided) without first determining the cause of the alarm and ensuring resident safety. Further, facility staff failed to communicate to the appropriate staff in a timely manner regarding the resident’s prior elopement attempts to leave the facility when he/she previously had gone out exit doors. Not all nursing staff were aware of this behavior, and this information had not been properly communicated to charge nurses and/or to the interdisciplinary care plan team members in order for specific and measurable interventions to be put into place to address the resident’s increased supervision needs when he/she displayed behavior changes, e.g. constantly wanders at times toward the doors and says he/she is looking for his/her mother and/or closely follows after people at times within the facility as he/she likes to be near people, e.g. staff who complete the medication pass. On 11/21/08, the resident wore an electronic elopement prevention device which would cause an alarm to sound at any of the facility exit doors in resident use areas once the resident approached the exit door. Staff on duty at the time of the resident’s elopement from the facility after dark on 11/21/08 were uncertain if a door alarm had sounded or not. Resident #1 was found lying on the ground approximately 40 feet outside of the 300 Hall exit door, was cold and shivering with a low body temperature and rapid breathing, was transferred to a local hospital emergency room by ambulance, was treated with equipment to warm his/her body temperature, was admitted to the hospital’s Critical Care Unit (CCU), and was diagnosed with hypothermia (abnormally low body temperature that occurs when more heat escapes from your body than your body can produce; signs and symptoms of hypothermia may include gradual loss of mental and physical abilities, for example, it can make you sleepy, confused and clumsy). | ||
| Facility:
Edgewood Manor Nursing Home
Raytown, MO 60-Bed Skilled Nursing Facility Date of Notice: December 2008 |
Owner: Deaconess Long Term
Care of Missouri, Inc.
Operator: Same Registered Agent: The Corporation Company |
Legal Action: Class I Notice of Noncompliance |
| Description: Based on record review and interview, the facility staff failed to ensure licensed nursing staff provided appropriate care to promote healing and prevent the decline and deterioration of one discharged resident’s (Resident #2) pressure ulcers (any lesion caused by unrelieved pressure resulting in damage of underlying tissue). The licensed nursing staff failed to complete and accurately document ongoing assessments including the resident’s wound sites, characteristics of the resident’s pressure ulcers which includes appropriate staging and assessment of the extent of the tissue damage of the resident’s pressure ulcers; and failed to update the resident’s comprehensive skin integrity care plan to reflect the resident’s current condition and new treatment interventions of the resident’s pressure ulcers when the resident’s physician ordered a change in treatment and when the condition of the resident’s pressure ulcers declined. Further, the facility failed to ensure all licensed charge nurses who provided wound care were adequately trained to assess and provide care for residents with pressure ulcers. Staff failed to document and assess a second pressure ulcer on the resident’s right hip which was later identified when the resident was admitted to the hospital. On 09/23/2008, the facility staff identified Resident #2 with one facility-acquired pressure ulcer on his/her right buttock and obtained treatment orders. From 09/23/2008 to 11/10/20008, staff had only identified and obtained treatment orders for one pressure ulcer on the resident’s right buttocks. On 11/23/2008, the facility transferred Resident #2 to the hospital due to the resident’s decline. According to the resident’s nurse’s note dated 11/23/2008, the resident’s physician’s order was to send the resident to the hospital for evaluation and treatment to the resident’s right hip. The hospital staff identified two pressure ulcers, one on the resident’s right buttock and one on the resident’s right hip that were connected under the resident’s skin with yellow purulent (pus indicating the presence of infection) drainage. In addition, the facility staff failed to prevent Resident #17 from developing a pressure ulcer on his/her right inner heel as staff failed to provide proper-fitting footwear to the resident which contributed to the resident developing a Stage II pressure ulcer on his/her right inner heel; failed to prevent the resident’s pressure ulcer from becoming infected; failed to consistently document all the pertinent information about Resident #17’s pressure ulcer; and failed to ensure that wheelchair foot rests were consistently available to keep Resident #17’s feet off the floor. There were 11 total sampled residents with a facility census of 56 residents. | ||
|
NORTHEAST REGION | |||
| Facility: Milan
Health Care
Milan, MO 100-Bed Skilled Nursing Facility Date of Notice: January 2008 |
Owner:
B & T Partnership
Operator: N & R of Milan, Inc. Registered Agent: Charlotte Stutts |
Legal Action: Uncorrected Class II Notice of Noncompliance | |
| Description: The facility failed to ensure one resident received adequate supervision to prevent an accident. The resident received second degree burns. | |||
| Facility:
Coates Street Comfort House
Moberly, MO 20-Bed Residential Care Facility Date of Notice: January 2008 |
Owner: Jones,
Chris L.
Operator: Coates Street Comfort House LLC Registered Agent: Chris Jones |
Legal Action: Uncorrected Class II Notice of Noncompliance | |
| Description: The facility failed to ensure that one of two employees reviewed, Certified Medication Aide (CMA) C, who had been convicted of criminal offenses related to controlled substances did not have access to controlled substances at the facility. The facility failed to administer noontime medication to one of two sampled residents (Resident #7). | |||
| Facility:
Crosspointe RCF
Edina, MO 47-Bed Residential Care Facility Date of Notice: January 2008 |
Owner: Not
Listed
Operator: W.L.E., LLC Registered Agent: Dewayne Wellborn |
Legal Action: Uncorrected Class II Notice of Noncompliance | |
| Description: The facility failed to maintain five of six remote exits and the path of egress leading from those exits free of obstruction. The administrator failed to properly supervise and oversee the appropriate reimbursement of residents’ funds, failed to ensure the facility was in compliance with fire safety requirements, and ongoing issues related to a safe and clean environment. The facility failed to use the personal funds of residents exclusively for the use of the residents. | |||
| Facility:
Silex Community Care
Silex, MO 60-Bed Skilled Nursing Facility Date of Notice: February 2008 |
Owner: Not
Listed
Operator: N & R of Silex Registered Agent: Charlotte Stutts |
Legal Action: Class I Notice of Noncompliance | |
| Description: The facility failed to provide the necessary care and services to maintain the highest practicable physical well-being for one of seven residents (Resident #1) with physician’s orders for Coumadin (a blood anticoagulant) therapy. Facility staff failed to accurately transcribe the resident’s admission physician’s orders for medication, failed to ensure lab tests were completed as ordered and failed to adequately assess and monitor the resident’s Coumadin therapy who developed critical lab values (prolonged blood clotting times and low red blood cell count), had to be hospitalized, and subsequently died at the hospital with his/her cause of death as cardiopulmonary arrest, severe anemia, and gastrointestinal bleeding. The facility census was 53. | |||
| Facility:
Milan Health Care Facility
Milan, MO 100-Bed Skilled Nursing Facility Date of Notice: February 2008 |
Owner: B &
F Partnership
Operator: N & R of Milan, Inc. Registered Agent: Charlotte Stutts |
Legal Action: Class I Notice of Noncompliance | |
| Description: The facility failed to follow physician orders and obtain laboratory tests (PT/INR) to monitor the blood level of Coumadin (inhibits the blood from forming clots and can cause hemorrhage. The physician determines the proper dosage based on the blood levels.) Staff failed to ensure laboratory testing was done as ordered on 12/21/07, 12/25/07, 12/28/07 and on 1/1/08. Nursing staff documented the resident began having signs of internal bleeding on 12/20/07 and that the resident’s blood pressure began dropping on 1/4/08. Blood tests done on 1/4/08 revealed the resident had a very high PT/INR level. Staff transferred the resident to the hospital on 1/5/08. Diagnoses included an upper gastro-intestinal (GI) bleed. The resident died on 1/8/08 with diagnoses of GI bleed, hypotension, myocardial infarction (heart attack) and supratherapeutic (excessive or very high) PT/INR level. | |||
| Facility:
La Belle Manor Care Center
La Belle, MO 94-Bed Skilled Nursing Facility Date of Notice: February 2008 |
Owner: La Belle
Manor, Inc.
Operator: Same Registered Agent: Samuel Bevill |
Legal Action: Class I Notice of Noncompliance | |
| Description: A complaint investigation was completed on 1/18/08. The facility was not in substantial compliance with participation requirements. The facility failed to provide the necessary care for one resident when staff failed to initiate Cardio-Pulmonary Resuscitation when staff found a resident dying and records showed the resident was a full code. On 12/19/07 at approximately 11:45 p.m., staff found the resident unresponsive, upon repositioning the resident took several breaths. Licensed staff took the resident’s vital signs and got no vital signs, staff did not initiate CPR and did not call 911. The resident expired 12/20/07. | |||
| Facility:
North Village Park
Moberly, MO 184-Bed Skilled Nursing Facility Date of Notice: February 2008 |
Owner: MS
Associates LP
Operator: North Village Park, LLC, Reliant Care North Village LLC Registered Agent: Joanna Owen |
Legal Action: Class I Notice of Noncompliance | |
| Description: The facility failed to ensure each resident receives the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well being in accordance with comprehensive assessment and plan of care and ensure each resident receives adequate supervision and assistance devices to prevent accidents. On 12/27/07, the facility failed to ensure staff immediately contacted Emergency Medical Services (911), or immediately provided cardiopulmonary resuscitation (CPR) after assessing one resident, (Resident #1), a resident who presented as Full Code, without respirations or a pulse. After finding the resident unresponsive with no respirations the licensed nurse assessed the resident by evaluating the radial and apical pulses, attempted to obtain a blood pressure and then left the resident’s room to use a facility telephone at the nurse’s desk to contact another staff member prior to initiating CPR. The facility staff initiated CPR approximately 5 minutes after assessing the resident as unresponsive without respirations and contacted EMS approximately eight minutes after assessing the resident as unresponsive without respirations. Also, before midnight on 1/25/08, a resident (Resident #3) left the facility’s locked unit without staff’s knowledge, while the resident was on five-minute face checks. Staff were not aware the resident left the facility until the facility received a telephone call at approximately 2:45 a.m. on 1/26/08, after the resident contacted off duty staff. The resident did not return to the facility until approximately 10:00 p.m. on 1/26/08 after staff traveled approximately 134 miles to meet the resident and return him/her to the facility. | |||
| Facility:
Maple Lawn Nursing Home
Palmyra, MO 140-Bed Skilled Nursing Facility Date of Notice: February 2008 |
Owner: Marion
County Nursing Home District
Operator: Same Registered Agent: Not Listed |
Legal Action:
Uncorrected Class II Notice of Noncompliance In a letter from DHSS: On 12/11/2008, SLCR staff completed a revisit at the facility and determined that the Class I deficiency could be lowered to a Class II.
| |
| Description: The facility staff failed to provide services that meet professional standards of nursing practice by failure to routinely assess the vital signs of one resident (Resident #207) of 14 sampled residents to ensure the vital signs were within acceptable parameters to administer Metoprolol (a blood pressure medication). | |||
| Facility:
Moore-Pike Nursing Home
Bowling Green, MO 64-Bed Skilled Nursing Facility Date of Notice: February 2008 |
Owner: Pike
County Court
Operator: Moore-Pike Nursing Home Registered Agent: Martha E. Moore |
Legal Action: Uncorrected Class II Notice of Noncompliance | |
| Description: A survey was completed on 12/13/07. The facility was not in substantial compliance with participation requirements. A revisit was completed on 2/07/08. The facility failed to ensure residents received adequate supervision and assistive devices to prevent the potential for injuries during transfers. Facility staff failed to appropriately transfer three residents in accordance with the residents’ plan of care and without the use of an assistive device by grasping under the residents under the arms. (Sic) Transferring residents by lifting them under their arms could result in skin tears, damage to nerves and arteries and possible dislocation of the shoulder. | |||
| Facility:
Monroe Manor
Paris, MO 119-Bed Skilled Nursing Facility Date of Notice: March 2008 |
Owner: Monroe
County Nursing Home District
Operator: Same Registered Agent: Not Listed |
Legal Action: Class
I Notice of Noncompliance In a letter from DHSS: On 4/01/2008, SLCR staff completed a revisit at the facility and determined that the Class I deficiency could be lowered to a Class II.
| |
| Description: The facility failed to develop and implement interventions to address swallowing problems, provide supervision to prevent choking or aspiration, failed to implement interventions already identified to prevent ongoing episodes of choking and aspiration for one of twelve samples residents, and failed to provide supervision with eating for one of three expanded sampled residents, who was a high risk for aspiration. In addition, the facility staff failed to perform transfers with the Hoyer lift in a manner to assure the resident’s safety for one sampled resident and one additional resident. | |||
| Facility:
Crosspointe RCF
Edina, MO 47-Bed Residential Care Facility Date of Notice: March 2008 |
Owner: W.L.E.
LLC
Operator: Same Registered Agent: Dewayne Wellborn |
Legal Action: Uncorrected Class II Notice of Noncompliance | |
| Description: A revisit was completed at the facility on 2/29/08. The facility had uncorrected Class II violations. The census was 32 residents. The facility failed to: Vent dryers to the outside of the building. Maintain the exterior of the building and interior walls in good repair. Ensure vent covers were in place and that exhaust fans and floor fans were clean. Ensure one of nine emergency lights was in working order. Ensure two residents did not reside in unheated basement rooms when room temperatures dropped below 68 degrees Fahrenheit. | |||
| Facility:
Troy Manor LLC
Troy, MO 130-Bed Skilled Nursing Facility Date of Notice: March 2008 |
Owner: Not
Listed
Operator: Troy Manor, LLC Registered Agent: Stuart J. Vogelsmeier |
Legal Action: Class I Notice of Noncompliance | |
| Description: The facility staff failed to provide the necessary care and services for two of three closed record reviewed residents (Resident #19 and #20) and one additional resident (Resident #60). Staff failed to have a system in place to assure a continuity of care related to newly admitted Resident #19 and #20’s medications, treatments, and/or labs. Staff failed to have a system in place to assure that Resident #19’s medications were pre-ordered or promptly ordered at the time of the resident’s admission. Staff failed to accurately transcribe and administer Resident #19’s medication. Staff failed to use the same medication available in the facility’s emergency kit when Resident #19’s medications were not available by individual prescription form. Staff failed to notify Resident #19’s physician regarding medications that were not administered to the resident. Staff failed to thoroughly assess and evaluate Resident #19, #20, and #60’s declining conditions in a timely manner. Staff failed to contact Resident #20’s physician regarding a change in his/her mental and physical status. Staff failed to promptly notify the physician of significant changes in each resident’s condition related to each resident’s diagnoses, which jeopardized each resident’s health. Resident #19, #20, and #60 were each transferred to a hospital for further evaluation and care. Resident #20 expired at the hospital on 01/01/2008. | |||
| Facility: Lynn’s Heritage House Inc.
Louisiana, MO 44-Bed Residential Care Facility Date of Notice: April 2008 |
Owner: Not
Listed
Operator: Lynn’s Heritage House, Inc. Registered Agent: Karen R. Lynn |
Legal Action: Uncorrected Class II Notice of Noncompliance | |
| Description: A complaint investigation was completed on 2/08/08. The facility was not in substantial compliance with participation requirements. A revisit was completed on 3/20/08. The facility failed to ensure residents received proper care to meet their needs. The facility staff failed to monitor or implement interventions to address pressure relief for one resident with a pressure sore. | |||
| Facility:
Sunshine Home Care
Winfield, MO 45-Bed Residential Care Facility Date of Notice: April 2008 |
Owner: Kromal,
Inc.
Operator: Sunshine Home Care, LLC Registered Agent: Shahid Hussain |
Legal Action: Uncorrected Class II Notice of Noncompliance | |
| Description: A complaint investigation was completed on 1/08/08. The facility was not in compliance with participation requirements. A revisit was completed on 4/02/08. The facility failed to ensure physician instructions/orders were followed. The facility staff failed to document Accu check readings and administer insulin as ordered by the resident’s physician. In addition staff failed to administer the correct dose of insulin based on the sliding scale physician order. | |||
| Facility:
Moberly Nursing & Rehab
Moberly, MO 120-Bed Skilled Nursing Facility Date of Notice: April 2008 |
Owner:
Ravenwood Manor Home, Inc.
Operator: N & R of Moberly, Inc. Registered Agent: Charlotte Stutts |
Legal Action:
Class I Notice of Noncompliance In a letter from DHSS: On 5/01/2008, SLCR staff completed a revisit at the facility and determined that the Class I deficiency could be lowered to a Class II.
| |
| Description: A complaint investigation was completed at the facility on 4/16/08. The facility was not in compliance with participation requirements. The facility staff failed to inform the resident’s physician when the resident had a significant change in his/her physical and mental status. In addition, the facility failed to provide the necessary care and services when the resident’s condition declined. The facility admitted resident #1 on 1/14/08 because of an infection in a surgical wound in the back. The facility expected to discharge the resident home after a four to six week stay at the facility. By 1/23/08, the resident complained of nausea and vomiting, a sore throat and was hoarse. The resident’s condition continued to decline with little to no oral intake, decreased urinary output and the resident had become lethargic, confused and unable to swallow without difficulty. On 1/26/08, Resident #1 required suctioning because of “gurgling” sounds in the throat. However, staff administered oral medications to the resident, did not inform the physician of the resident’s decline and subsequent unresponsiveness. Staff continued to monitor the resident for three hours and did not transfer the resident to the hospital until requested to do so by family members of 126/08. Resident #1 expired on 1/27/08. The immediate cause of death was sepsis due to or as a consequence of aspiration. Contributing factors were acute renal failure, respiratory failure and aspiration pneumonia. | |||
| Facility:
Schuyler County Nursing Home
Queen City, MO 60-Bed Skilled Nursing Facility Date of Notice: May 2008 |
Owner: Schuyler
County Nursing Home District
Operator: Same Registered Agent: Not Listed |
Legal Action: Uncorrected Class II Notice of Compliance | |
| Description: A survey was completed at the facility on 3/12/08. The facility was not in substantial compliance with participation requirements. A revisit was completed on 5/02/08. The facility failed to provide adequate oversight and supervision to address one resident’s risk for falls, when the resident attempted to slide out of his/her geri chair with tray in place and caught his/her head on one side of the chair and body on the other side. Facility staff failed to ensure the resident was free from restraints or the least restrictive device was used to treat a medical symptom. In addition the facility failed to ensure each resident received education regarding the benefits and potential side effects of the influenza pneumococcal immunizations. | |||
| Facility:
Levering Regional Health Care Center
Hannibal, MO 120-Bed Skilled Nursing Facility Date of Notice: May 2008 |
Owner: Levering
Associates, LLC
Operator: Levering Regional Health Care Center, LLC Registered Agent: Robert J. Craddick |
Legal Action: Class I Notice of Noncompliance | |
| Description: A complaint investigation was completed on 5/13/08. The facility was not in substantial compliance with participation requirements. The facility failed to immediately provide cardiopulmonary resuscitation (CPR) after assessing one resident, who presented as full code, without respirations or a pulse. | |||
| Facility:
Georgia Brown Blosser Home for the Aged
Marshall, MO 11-Bed Residential Care Facility Date of Notice: May 2008 |
Owner: Georgia
Brown Blosser Home for the Aged
Operator: Same Registered Agent: Not Listed |
Legal Action: Uncorrected Class II Notice of Compliance | |
| Description: SLCR completed the annual licensure inspection on 2/14/08 with violations cited. A revisit was completed on 5/15/08. The facility had an uncorrected violation in the area of Administrative, Personnel and Resident Care requirements. The facility failed to screen 6 of 7 residents and 8 of 11 employees for tuberculosis using the two-step tuberculin test as required for long-term care facilities by 19 CSR 20-20.100. The facility census was 7 residents. | |||
| Facility:
Sunshine Home Care
Winfield, MO 45-Bed Residential Care Facility Date of Notice: May 2008 |
Owner: Sunshine
Home Care St. Charles LLC
Operator: Sunshine Home Care, LLC Registered Agent: Not Listed |
Legal Action: Class I Notice of Noncompliance | |
| Description: A 4/24/08 a complaint investigation was completed. The facility was not in substantial compliance with participation requirements. The facility failed to provide protective oversight for two residents (Resident #22 and #30) to ensure residents did not leave the facility without staff knowledge or inquiry into residents length of absence and whereabouts while on leave. The facility staff noted Resident #22 was missing on 4/20/08 at 12:00 p.m., but did not notify the manager until an hour and a half later. The resident did not have his/her psychotropic medications to treat his/her schizophrenia with hallucinations, alcohol/drug abuse and suicidal ideations. The resident was missing from the facility for two days before returning. Resident #30 diagnosis included schizophrenia with bizarre behaviors was found walking along a state highway 2 to 3 miles from town. | |||
| Facility:
Luther Manor Retirement and Nursing Center
Hannibal, MO 60-Bed Skilled Nursing Facility Date of Notice: June 2008 |
Owner: Luther
Manor Association
Operator: Same Registered Agent: Sharon K. Moore |
Legal Action: Uncorrected Class II Notice of Noncompliance | |
| Description: A licensure inspection was completed on 3/26/08. The facility was not in substantial compliance with participation requirements. The facility failed to follow physician orders and ensure medications were available for two residents. | |||
| Facility:
Lynns Heritage House, Inc.
Louisiana, MO 44-Bed Residential Care Facility Date of Notice: June 2008 |
Owner: Not
Listed
Operator: Lynns Heritage House, Inc. Registered Agent: Karen Lynn |
Legal Action: Uncorrected Class II Notice of Noncompliance | |
| Description: A complaint investigation was completed on 2/08/08. The facility was not in substantial compliance with participation requirements. A revisit was completed on 3/20/08 and 5/22/08. The facility failed to correct deficiencies related to maintaining one hour separation in the attic when one of four smoke dampers failed to function. | |||
| Facility:
Sunshine Home Care
Winfield, MO 45-Bed Residential Care Facility Date of Notice: July 2008 |
Owner: Not
Listed
Operator: Sunshine Home Care, LLC Registered Agent: Shahid Hussain |
Legal Action: Class I Notice of Noncompliance | |
| Description: The facility failed to provide oversight to one resident (Resident #8), under guardianship with a history of alcohol abuse resulting in the resident signing out to go for a walk and returning to the facility approximately 2/1/2 hours later in an intoxicated state, and in the custody of the local police. The police found the resident standing on a Mississippi River levee approximately 4 blocks from the facility. Due to extensive rainfall and flooding in the region, the National Guard had been called in to sandbag the area. The police were on flood patrol when the discovered the resident standing on the levee. The same levee was breached the next morning sending additional floodwaters toward the town. | |||
| Facility:
Sunshine Home Care
Winfield, MO 45-Bed Residential Care Facility Date of Notice: July 2008 |
Owner: Not
Listed
Operator: Sunshine Home Care, LLC Registered Agent: Shahid Hussain |
Legal Action: Class I Notice of Noncompliance | |
| Description: A licensure inspection and complaint investigation was completed on 6/19/08. The facility was not in substantial compliance with participation requirements. The facility failed to provide protective oversight and supervision to one resident with a history of elopements from leaving the facility. An anonymous caller contacted the facility and informed staff the resident on a bus headed for New York. The resident’s whereabouts remains unknown. | |||
| Facility:
Clarence Care Center
Clarence, MO 60-Bed Skilled Nursing Facility Date of Notice: August 2008 |
Owner: Clarence
Nursing Home District
Operator: Same Registered Agent: Not Listed |
Legal Action: Uncorrected Class II Notice of Noncompliance |
| Description: A survey was completed on 6/05/08. The facility was not in substantial compliance with participation requirements. A revisit was completed on 7/23/08. The facility failed to: Follow standards of practice by not properly identify medications removed from original containers and placed in medication cups prior to the medication pass. Ensure one resident received adequate supervision and assistance devices to prevent accidents. Ensure nursing staff washed their hands and change gloves after performing perineal care and before providing continued personal care. | ||
| Facility: Silex
Nursing Center
Silex, MO 60-Bed Residential Care Facility Date of Notice: September 2008 |
Owner: Silex Nursing
Center, Inc.
Operator: Same Registered Agent: Mathisa P. Dasal |
Legal Action: Uncorrected Class II Notice of Noncompliance |
| Description: A licensure inspection was completed at the facility on 6/13/08. The facility was not in substantial compliance with participation requirements. The facility failed to properly manage resident trust funds by allowing fourteen residents to overspend their accounts and spending other resident’s money without their authorization. In addition the facility failed to place all resident funds in an account separate from the facility’s operating account. The facility held $30,847.24 in the facility operating account. | ||
| Facility:
Sunshine Home Care
Winfield, MO 45-Bed Residential Care Facility Date of Notice: September 2008 |
Owner: Kromal, Inc.
Operator: Sunshine Home Care, LLC Registered Agent: Tariq E. Malik |
Legal Action: Uncorrected Class II Notice of Noncompliance |
| Description: A licensure inspection and complaint investigation was completed on 06/19/08. The facility was not in substantial compliance with participation requirements. A revisit was completed on 09/08/08. The facility failed to take corrective action in the following areas: Ensure residents smoked only in designated area with supervision. Ensure only one appliance be connected to one extension cord and two appliances in a multi-outlet power strip. Maintain furniture in good condition. Ensure water temperatures range between 105 degrees Fahrenheit and 120 degrees F. Screen residents and employees for tuberculosis. Ensure staff followed appropriate infection control procedures during accuchecks. Implement a safe and effective medication administration system. Ensure physician orders are followed. Ensure a review of modified diets completed by a qualified individual. Obtain a modified diet menus with portion sizes. Store toxic materials in a manner not accessible to residents. Maintain carpeted floors in a clean condition. Ensure employees wash their hands to protect food from potential contamination. Ensure all written accounts were current and reconciled with resident trust fund account. | ||
| Facility:
Crosspointe RCF
Edina, MO 47-Bed Residential Care Facility Date of Notice: October 2008 |
Owner: WLE, LLC
Operator: Same Registered Agent: Dewayne Wellborn |
Legal Action: Uncorrected Class II Notice of Noncompliance |
| Description: A licensure inspection was completed on 1/04/07. The facility was not in substantial compliance with participation requirements. A revisit and annual licensure inspection was conducted on 9/25/08 by SLCR and Division of Fire Safety. The facility failed to: Assure compliance with all applicable laws and regulations. Ensure residents did not administer their own medication without physician approval/order. Ensure a safe and effective medication system, with a medication error rate of 17.6%. Assure residents or their designee authorized, in writing, for the facility to hold safeguard and manage resident funds. Ensure resident trust fund accounts were reconciled on a monthly basis in an account separate from facility operating account. Maintain one hour fire rated doors with a self closing device in the furnace and electrical rooms. Ensure no portion of the facility presented a fire hazard when storing combustible materials in a hazardous area. | ||
| Facility: Pioneer
Skilled Nursing Center
Marceline, MO 96-Bed Skilled Nursing Facility Date of Notice: December 2008 |
Owner: Pioneer Nursing,
LLC
Operator: Same Registered Agent: Husch Registered Agent, Inc. |
Legal Action: Uncorrected Class II Notice of Noncompliance |
| Description: A survey was completed on 09/18/08. The facility was not in substantial compliance with participation requirements. A revisit was completed on 11/13/08. The facility failed to achieve compliance in the following areas: Obtain and administer medications as ordered by the physician. Ensure staff provided the necessary care and services to maintain good personal hygiene when providing incontinence care to residents. Ensure nursing staff washed their hands after each direct resident contact to prevent the spread of infection. | ||
| Facility: Maple
Lawn Nursing Home
Palmyra, MO 140-Bed Skilled Nursing Facility Date of Notice: December 2008 |
Owner: Marion County
Nursing Home District
Operator: Same Registered Agent: Not Listed |
Legal Action: Class I
Notice of Noncompliance In a letter from DHSS: On 12/11/2008, SLCR staff completed a revisit at the facility and determined that the Class I deficiency could be lowered to a Class II.
|
| Description: A complaint investigation was completed on 11/25/08. The facility as not in substantial compliance with participation requirements. The facility failed to provide appropriate nursing care to one resident who presented as a Full Code when staff found the resident without pulse or respirations. Facility staff failed to initiate Cardiopulmonary resuscitation after assessing the resident without pulse or respirations and the resident subsequently died. | ||
|
NORTHWEST REGION | |||
| Facility:
Ashton Court Care & Rehab Center
Liberty, MO 140-Bed Skilled Nursing Facility Date of Notice: January 2008 |
Owner:
Not Listed
Operator: Ashton Court Healthcare, LLC Registered Agent: CS-Lawyers Incorporating Service |
Legal Action: Uncorrected Class II Notice of Noncompliance | |
| Description: A licensure inspection and complaint investigation was completed on 11/07/07. The facility was not in substantial compliance with participation requirements. A revisit was completed on 1/04/08. The facility staff failed to make correction of the following violations: provide emergency exit lighting to illuminate the path of safety from areas immediately outside exit door to the public way; maintain sprinkler heads free of paint and insulation to ensure proper functioning in the event of a fire; maintain water pipes to prevent water from leaking into resident rooms; ensure staff treat residents with dignity and respect; complete an inquiry to the highway patrol for criminal records for the purpose of conducting criminal background checks as directed in state statute. | |||
| Facility:
Excelsior Springs Nursing & Rehab
Excelsior Springs, MO 108-Bed Skilled Nursing Facility Date of Notice: January 2008 |
Owner: Not
Listed
Operator: Excelsior Springs Nursing & Rehab LLC Registered Agent: Charlotte Stutts |
Legal Action: Uncorrected Class II Notice of Noncompliance | |
| Description: The facility failed to follow the policy and procedure, and provide perineal care in a manner to decrease the risk of urinary tract infections. The facility staff also failed to assess a resident for signs and symptoms of infection. The facility failed to ensure staff kept residents clean, dry, and odor free. | |||
| Facility:
Arbor View Healthcare and Rehab Center
St. Joseph, MO 120-Bed Skilled Nursing Facility Date of Notice: January 2008 |
Owner: Not
Listed
Operator: Five Star Quality Care, Inc. Registered Agent: CSC-Lawyers Incorporating Service Co. |
Legal Action: Class I and Uncorrected Class II Notice of Noncompliance | |
| Description: The facility failed to follow their procedure in performing the Heimlich maneuver for one resident when he/she choked at the evening meal. The facility failed to ensure staff followed physician’s orders for two residents. The facility staff failed to provide incontinent care for two residents. The facility failed to assess and treat sores on one resident who staff identified at risk for skin breakdown. | |||
| Facility:
Clinton Care and Rehab Center
Plattsburg, MO 70-Bed Skilled Nursing Facility Date of Notice: February 2008 |
Owner: Not
Listed
Operator: N & R of Plattsburg, LLC Registered Agent: Charlotte Stutts |
Legal Action: Uncorrected Class II Notice of Noncompliance | |
| Description: The facility failed to monitor and treat symptoms of pain and failed to timely obtain a urinalysis for one resident who had a urinary tract infection. The facility failed to obtain laboratory services for one resident in a timely manner, as ordered by the physician. | |||
| Facility:
Cedars of Liberty, Inc.
Liberty, MO 206-Bed Residential Care Facility Date of Notice: February 2008 |
Owner: Not
Listed
Operator: Cedars of Liberty, Inc. Registered Agent: James L. Webb |
Legal Action:
Class I Notice of Noncompliance In a letter from DHSS: On 6/12/2008, SLCR staff completed a revisit at the facility and determined that the Class I deficiency could be lowered to a Class II.
| |
| Description: A complaint investigation was completed on 1/31/08. The facility was found not to be in substantial compliance with participation requirements. The facility staff failed to provide adequate monitoring and prevention to assure one resident’s blood glucose level did not drop dangerously low and he/she sustained injuries after nursing staff administered his/her morning insulin and he/she did not eat breakfast. Staff administered the resident’s insulin at 6:30 a.m. and the resident informed staff he/she was not going to eat breakfast and didn’t feel well. Staff did not recheck the resident’s blood glucose level or obtain food for the resident to address his/her blood glucose level. When emergency personnel arrived the resident’s blood glucose reading was 40 placing the resident at risk for serious injury. | |||
| Facility:
Cameron Nursing and Rehabilitation Center
Cameron, MO 120-Bed Skilled Nursing Facility Date of Notice: February 2008 |
Owner: Euclid
Properties LLC
Operator: Cameron Nursing and Rehabilitation Center, LLC Registered Agent: National Registered Agents, Inc. |
Legal Action: Uncorrected Class II Notice of Noncompliance | |
| Description: The facility failed to assess, monitor, and identify symptoms of a urinary tract infection for one resident (Resident #30) with a history of urinary tract infections and frequent urinary incontinence. The facility failed to ensure Resident #30 received timely care and treatment. | |||
| Facility:
Hillview Nursing & Rehab
Platte City, MO 120-Bed Skilled Nursing Facility Date of Notice: February 2008 |
Owner:
Plattecare, Inc.
Operator: N & R of Platte City Registered Agent: Charlotte Stutts |
Legal Action: Uncorrected Class II Notice of Noncompliance | |
| Description: The facility failed to provide adequate supervision and protective oversight for one resident (Resident #22) who receives a specialized mechanical soft diet by allowing a visitor to serve pizza to the resident. The resident choked on the pizza, went into cardiac arrest (occurs when the heart develops an arrhythmia that causes it to stop beating), and had to be transported to the hospital. This had the potential to affect 21 residents whom the facility identified as having physician’s orders to receive a mechanical soft diet. The facility failed to ensure staff clarified physicians’ orders and administered medication per physicians’ orders appropriately for one of 15 sampled residents (Resident #22). The facility failed to ensure staff provided oral care to one of 15 sampled residents (Resident #18). The facility failed to ensure a non-certified nurse’s aide employed at the facility had completed the State-approved training and competency evaluation program within four months of their full-time employment date. This had the potential to affect all residents who reside at the facility. | |||
| Facility:
Saxton Woods Care Center
St. Joseph, MO 240-Bed Skilled Nursing Facility Date of Notice: March 2008 |
Owner: Saxton
TLC, Inc.
Operator: Caring for Seniors, Inc. Registered Agent: Glen Muir |
Legal Action:
Uncorrected Class II Notice of Noncompliance In a letter from DHSS: On 5/08/2008, SLCR staff completed a revisit at the facility and determined that the Class I deficiency could be lowered to a Class II.
| |
| Description: The facility failed to assess one resident’s skin under a splint, and failed to implement measures to ensure the resident did not develop pressure ulcers located under the resident’s splint. The facility failed to ensure nurse aides successfully completed the nurse aide training course within four months of employment. | |||
| Facility:
Pleasant View
Rock Port, MO 60-Bed Skilled Nursing Facility Date of Notice: March 2008 |
Owner:
Mennonite Home Ass’n., Inc.
Operator: Tiffany Care Centers, Inc. Registered Agent: David Duncan |
Legal Action: Class I Notice of Noncompliance | |
| Description: The facility failed to assure staff implemented emergency procedures for one closed record resident (Resident #12) in a review of 12 residents, when one licensed staff person found the resident without a pulse and without respirations and failed to initiate cardiopulmonary resuscitation (CPR), and subsequently, the resident expired at the facility on 2/01/08. The facility failed to implement a consistent system to identify a resident’s code status (CPR or Do Not Resuscitate) for three of 12 sampled residents (Residents #12, #2, and #4). The facility failed to assure staff continued to assess and treat one of 12 sampled residents (Resident #2) for pain. | |||
| Facility:
Beautiful Savior Home
Belton, MO 126-Bed Skilled Nursing Facility Date of Notice: March 2008 |
Owner:
Beautiful Savior Home
Operator: Same Registered Agent: A. Glenn Sowders, Jr. |
Legal Action: Class I Notice of Noncompliance | |
| Description: Based on record review and interviews, the facility staff failed to assess and monitor the respiratory status, update the physician when the respiratory status worsened, and to provide medication/treatment as ordered by the physician for one resident (Resident #1) experiencing severe shortness of breath resulting in the resident having to be transferred to the hospital by ambulance where the resident rapidly declined and expired in the emergency room within two hours of arrival to the hospital; and further, the facility staff failed to assess, obtain physician’s orders, and provide interventions for a skin tear on Resident #1 who was one of four sampled residents. | |||
| Facility:
Valley Manor & Rehabilitation Center
Excelsior Springs, MO 120-Bed Skilled Nursing Facility Date of Notice: April 2008 |
Owner: Not
Listed
Operator: Excelsior Springs #1, Inc. Registered Agent: Not Listed |
Legal Action: Class I Notice of Noncompliance | |
| Description: The facility failed to assess the cause of falls for three sampled residents (Residents #1, #2, and #3) identified as high risk for falls, and failed to develop and implement interventions to prevent falls. Resident #1 had four falls from 12/26/07 to 2/17/08. Resident #1 sustained a laceration to one eyebrow that required stitches. The last fall occurred on 2/17/08 that resulted in cervical (neck) fracture, possible fracture of the base of the skull, and multiple facial bone fractures. The resident died in the hospital on 2/23/08. Resident #2 had a history of multiple falls. On 2/21/08, Resident #2 fell and sustained multiple orbital fractures (broken bones of the eye socket). Resident #3 fell and sustained a fractured humerus (upper bone of the arm). The facility census was 41. | |||
| Facility:
Living Community of St. Joseph
St. Joseph, MO 96-Bed Skilled Nursing Facility Date of Notice: April 2008 |
Owner: Living
Community of St. Joseph
Operator: Same Registered Agent: Christine Kerns |
Legal Action: Uncorrected Class II Notice of Noncompliance | |
| Description: SLCR completed an inspection on 2/20/08. At the time of the revisit, the facility was not in substantial compliance. The facility failed to date insulin vials when opened. The facility also failed to follow manufacturer’s recommendations and discard opened insulin vials after 28 days. | |||
| Facility:
Saxton Care Chateau
St. Joseph, MO 69-Bed Skilled Nursing Facility Date of Notice: April 2008 |
Owner: Saxton
Care Chateau, Inc.
Operator: Chateau Place, Inc. Registered Agent: Glen Muir |
Legal Action:
Class I Notice of Noncompliance In a letter from DHSS: On 4/24/2008, SLCR staff completed a revisit at the facility and determined that the Class I deficiency could be lowered to a Class II.
| |
| Description: SLCR completed a complaint investigation on 4/11/08. The facility failed to ensure Resident #1 was free of chemical restraints when staff repeatedly administered as needed (prn) antipsychotic and antianxiety/sedative medications to control behaviors. Staff failed to implement interventions to prevent or minimize behaviors, failed to monitor for side effects of the medication, failed to inform the physician of a decline in condition due to the side effects of the medication and failed to promptly act when Resident #1 became lethargic and required hospitalization. | |||
| Facility:
Saxton’s Country Villa
St. Joseph, MO 100-Bed Assisted Living Facility Date of Notice: May 2008 |
Owner:
Saxton’s, Inc.
Operator: Senior Life, Inc. Registered Agent: Glen Muir |
Legal Action:
Class I Notice of Noncompliance In a letter from DHSS: On 5/27/2008, SLCR staff completed a revisit at the facility and determined that the Class I deficiency could be lowered to a Class II. | |
| Description: The facility failed to provide protective oversight when Resident #1 eloped (left the facility without staff’s knowledge) on 5/3/08. Resident #1 wore a wrist WanderGuard bracelet (a device to alert staff that activates a door alarm when a resident tries to leave the facility). The resident had a history of elopement, and the facility documented three previous elopement attempts on 8/1/07, 8/15/07, and 4/24/08. On 5/3/08, a motorist found Resident #1 walking along the edge of a busy four lane highway. The motorist picked up the resident and summoned the police. The facility also failed to have a system in place for monitoring eight additional residents who wore WanderGuard devices. The facility census was 69. | |||
| Facility:
Clinton Care & Rehab Center
Plattsburg, MO 70-Bed Skilled Nursing Facility Date of Notice: May 2008 |
Owner: Clinton
are & Rehab Center
Operator: N & R of Plattsburg, LLC Registered Agent: Stephen W. Holden |
Legal Action: Uncorrected Class II Notice of Noncompliance | |
| Description: An annual inspection was completed on 12/03/2007 and a revisit was completed on 02/07/2008 and the facility was not in compliance. A second revisit was completed on 05/07/2008 and the facility was still not in compliance because of the following uncorrected violations. Each resident shall receive personal attention and nursing care in accordance with his/her condition and consistent with current acceptable nursing practice. The facility failed to assess, monitor and provide pain relief to two residents who complained of pain. The facility failed to ensure orders for laboratory tests were obtained in a timely manner for two residents who had symptoms of urinary tract infections. | |||
| Facility:
Saxton Woods Care Center
St. Joseph, MO 240-Bed Skilled Nursing Facility Date of Notice: May 2008 |
Owner: Saxton’s
TLC, Inc.
Operator: Careing for Seniors Registered Agent: Glen Muir |
Legal Action:
Class I and Uncorrected Class II Notice of Noncompliance In a letter from DHSS: On 5/08/2008, SLCR staff completed a revisit at the facility and determined that the Class I deficiency could be lowered to a Class II.
| |
| Description: SLCR completed a complaint investigation on 1/11/08 with deficiencies cited. At the revisit on 3/13/08, SLCR issued the facility an Uncorrected Class II Notice of Noncompliance. On 4/24/08, SLCR completed an annual licensure inspection and a revisit to the 3/12/08 notice of noncompliance. On 4/24/08, the facility census was 138 residents. CLASS I: The facility failed to implement and follow admission physician orders, including orders for oxygen and breathing treatments, for one resident (Resident #22) until approximately 12:00 a.m. on 4/5/08 after the facility admitted the resident on 4/4/08 at approximately 4:00 p.m. The facility failed to provide ongoing assessment and monitoring of the resident after the resident developed breathing difficulties. The facility failed to assure all licensed and direct care staff knew of the resident’s admission and failed to assure staff was aware of the resident’s care needs. Staff found the resident deceased on 4/5/08 at 9:00 a.m. UNCORRECTED CLASS II: The facility failed to ensure nurse aides (NAs) successfully completed the nurse aide training course within four months of employment at the facility. This had the potential to affect all residents. | |||
| Facility:
Shirkey Nursing & Rehab Center
Richmond, MO 187-Bed Skilled Nursing Facility Date of Notice: May 2008 |
Owner: Senior
Citizens N.H. District of Ray County
Operator: Same Registered Agent: Not Listed |
Legal Action: Class I Notice of Noncompliance | |
| Description: SLCR staff completed a complaint investigation on 4/24/2008. The facility failed to provide protective oversight to prevent one resident’s elopement from the facility without knowledge of staff. Facility staff failed to follow the facility policy when staff identified the resident had confusion and one previous episode of exiting the facility unaccompanied by staff. Staff failed to develop and implement effective interventions to prevent the resident from eloping from the facility, in a wheelchair, and propelling him/herself away from the facility and across a road, before daylight, without staff knowing resident had left. Facility staff also failed to respond to a exit door alarm, put in place to alert staff to persons entering and exiting the facility, which sounded when the resident opened the door and eloped from the facility. The facility census was 161. | |||
| Facility:
Abbey Woods
St. Joseph, MO 100-Bed Skilled Nursing Facility Date of Notice: June 2008 |
Owner: Not
Listed
Operator: Heritage Healthcare Holdings, Inc. Registered Agent: Lowell L. Fox, Jr. |
Legal Action: Uncorrected Class II Notice of Noncompliance | |
| Description: The annual inspection was completed on 4/1/08 with violations cited. At the revisit on 5/28/08, the facility failed to correct the cited violations. The facility failed to check the Employee Disqualification List and request a Criminal Background check for one staff person prior to allowing that employee to have contact with residents. | |||
| Facility:
Cedars of Liberty, Inc.
Liberty, MO 206-Bed Residential Care Facility Date of Notice: June 2008 |
Owner: Cedars
of Liberty, Inc.
Operator: Same Registered Agent: James L. Webb |
Legal Action:
Class I Notice of Noncompliance In a letter from DHSS: On 6/12/2008, SLCR staff completed a revisit at the facility and determined that the Class I deficiency could be lowered to a Class II.
| |
| Description: The facility failed to provide proper care to meet Resident #1’s needs. Resident #1 had a history of drinking alcohol in the facility. Facility staff failed to monitor Resident #1 for continued drinking or for keeping alcohol in the facility. The current physician orders showed Resident #1 had a full code status (wished to have CPR). On 5/3/08 at about 9:45 a.m., a maintenance person found the resident on the floor in the basement and the resident smelled of alcohol. The maintenance person informed the activity director but neither staff informed any of the nursing staff. At about noon on 5/3/08, nursing staff found the resident in his/her room lying on the bathroom floor. Staff assessed Resident #1 and found he/she did not have a pulse but did not start CPR according to the resident’s wishes, physician’s order and the facility policy. Staff called 9-1-1 and then called the resident’s on-call physician for a do not resuscitate order. During interviews, the on-call physicians said they did not remember being contacted by the facility and did not give the do no (sic) resuscitate order. Ambulance personnel arrived at the facility and determined Resident #1 had died. When police arrived at the facility, they found containers of alcohol in the resident’s room. | |||
| Facility:
Northview Manor
Tarkio, MO 95-Bed Skilled Nursing Facility Date of Notice: June 2008 |
Owner: Spiths
Properties Trust
Operator: Five Star Quality Care MO LLC Registered: CSC – Lawyers Incorporating Service Company |
Legal Action: Uncorrected Class II Notice of Noncompliance | |
| Description: The facility failed to assure staff provided adequate supervision and assistive devices for two residents (Resident #13 and #15) to prevent accidents. Staff failed to follow Resident #13’s plan of care, when staff failed to use the appropriate mechanical lift to transfer the resident which allowed the resident to fall and suffer a fractured shoulder. The facility failed to use foot pedals on Resident #15’s wheelchair before staff propelled the resident. This failure allowed the resident’s left foot to get caught on the carpeted floor which caused the resident’s left leg to bend backward under the wheelchair resulting in a left femur fracture which required surgical repair. The facility failed to separate four hazardous areas (ancillary/supply room, boiler room, soiled linen room and food storage room) from other portions of the building with doors that completely self-closed, were equipped with self-closing devices and had no impediments to closing. This affected two of eight smoke compartments (areas designed to limit the spread of fire and restrict the movement of smoke). | |||
| Facility:
Bethany Care Center
Bethany, MO 60-Bed Skilled Nursing Facility Date of Notice: July 2008 |
Owner: N &
R of Bethany, Inc.
Operator: Same Registered Agent: James C. Lincoln |
Legal Action: Uncorrected Class II Notice of Noncompliance | |
| Description: At the revisit on 7/1/2008, the facility failed to ensure a safe and effective medication system when a staff person did not administer medications as ordered to 11 residents. The facility further failed to follow physician orders and obtain and implement treatment orders for one resident with a wound on the left legs. (sic) The resident’s physician ordered staff to apply a wound evacuation device to remove drainage from the resident’s wound. The administrator told licensed nursing staff that she did not feel the device was an appropriate treatment and not to order the wound evacuation device. | |||
| Facility:
Nodaway Nursing Home
Maryville, MO 60-Bed Skilled Nursing Facility Date of Notice: July 2008 |
Owner: Nodaway
County Commission
Operator: Tiffany Care Centers, Inc. Registered Agent: David Duncan |
Legal Action: Uncorrected Class II Notice of Noncompliance | |
| Description: At the 7/1/2008 revisit, the facility failed to correct the following deficiencies: Staff failed to monitor eight residents for constipation and treat as necessary. Staff failed to prevent and identify newly developed pressure ulcers and failed implement measures to promote healing of existing pressures for two residents identified at risk. Staff failed to notify one resident’s physician when the resident had bleeding around the insertion site of an indwelling catheter. Staff failed to use appropriate transfer technique that caused the resident to be injured during the transfer. Staff failed to ensure staff administered medications as ordered. Staff failed to ensure the facility’s fire alarm system notified the remote station when trouble occurred in the system. | |||
| Facility:
Liberty Terrace Healthcare & Rehab
Liberty, MO 143-Bed Skilled Nursing Facility Date of Notice: July 2008 |
Owner: Liberty
Terrace Healthcare & Rehab
Operator: Liberty Terrace Healthcare & Rehab Center, LLC Registered Agent: National Registered Agents, Inc. |
Legal Action: Uncorrected Class II Notice of Noncompliance | |
| Description: At the revisit of 07/03/2008, the facility failed to: Develop and implement a policy and procedure for tracking lab results and notifying physicians of lab results. Staff failed to inform the physician of one resident’s change in condition and positive urine culture showing a urinary tract infection (UTI), failed to lab tests for one resident with continuing diarrhea which resulted in severe excoriation of his/her buttocks and inner thighs was done as ordered, failed to obtain a urine specimen in a timely manner for one sampled resident who had a UTI, and failed to identify and begin treatment in a timely manner for one resident with a painful tooth (related) infection. Ensure staff used techniques that reduced the possibility of injury during transfers for four residents. Ensure a safe and effective medication system with a medication error rate of 5% or lower. The facility had a medication error rate of 12.5%. | |||
| Facility:
Ashton Court Care & Rehabilitation Centre
Liberty, MO 140-Bed Skilled Nursing Facility Date of Notice: July 2008 |
Owner: Diamond
Senior Living
Operator: Ashton Court Healthcare, LLC Registered Agent: CSC – Lawyers Incorporating Service Company |
Legal Action: Class I Notice of Noncompliance | |
| Description: The facility failed to ensure residents on the special care unit were safe from possible burns when hot water on that unit was recorded from 128.9 degrees Fahrenheit to 149.3 degrees Fahrenheit. Forty-three residents resided on the unit. The facility census was 132. (At the time of the survey, on 7/8/08 the violation was gridded at “K” immediate and serious jeopardy level. On 7/15/08, the facility completed repairs to the hot water heater, monitored the hot water temperature for four days with all reading being in the normal range of below 120 degree Fahrenheit, trained staff on reporting hot water and what to do when the water exceeded 120 degree on a hall and was too hot for residents. On 7/15/08 grid placement scope and severity was lowered to an “E” level. This statement does not denote that the facility has complied with section 198.023.1 RSMo., regarding prompt remedial action for a violation of a Class I standard.) | |||
| Facility:
Quail Run Health Care Center
Cameron, MO 84-Bed Skilled Nursing Facility Date of Notice: July 2008 |
Owner: Cameron
Development Properties LLC
Operator: Cameron #1, Inc. Registered Agent: Clifton L. Shirrell |
Legal Action: Class I Notice of Noncompliance | |
| Description: Based on observation, interview and record review, the facility failed to conduct an on-going assessment, develop a care plan and provide adequate supervision for one (Resident #1) of 13 residents who the facility identified at risk for elopement. On 7/1/098 and twice on 7/9/08, the resident left the building unattended. On 7/9/08, after the resident exited the building into the parking lot a second time, staff placed the resident on the special care unit (locked unit) for one and one-half hours and then returned the resident to the unsecured North wing. On 7/12/08 at approximately 8:40 p.m., Resident #1 eloped from the facility. Facility staff became aware the resident had eloped after a couple traveling on 36 Highway saw the resident on the outer road and the couple drove to the facility to report to the staff. The resident had pushed his/her wheelchair to the outer road and traveled 0.1 mile from the facility. The facility failed to monitor the “Wanderguard” (an elopement bracelet placed on the wrist or ankle which causes an alarm to sound alerting staff that a resident was leaving the building) system and the exit doors daily per facility policy. The facility census was 41. | |||
| Facility:
Woodbine Healthcare and Rehab Center
Gladstone, MO 300-Bed Skilled Nursing Facility Date of Notice: July 2008 |
Owner: FCSCO
Properties I LLC
Operator: Woodbine Healthcare, LLC Registered Agent: Mark S. Rubin |
Legal Action: Uncorrected Class II Notice of Noncompliance | |
| Description: The facility failed to correct violations in the area of Resident Funds. The facility failed to place resident funds in an interest bearing account. The facility failed to notify residents when their SSI resources reached the limited amount. The facility failed to do monthly reconciliation of resident funds accounts. The facility failed to prevent commingling of petty cash funds. The facility failed to distribute monthly allowance. The facility imposed charges to a resident’s trust fund account when those services when payment is made under Medicaid. | |||
| Facility:
Bliss Manor
St. Joseph, MO 71-Bed Assisted Living Facility Date of Notice: July 2008 |
Owner: Not
Listed
Operator: Bliss Manor LLC Registered Agent: Brenda S. Wickman |
Legal Action: Uncorrected Class II Notice of Noncompliance | |
| Description: The facility failed to maintain the sprinkler system by not completing the quarterly inspections required by the National Fire Protection Association (NFPA) 13, and NFPA 25 Standard for the installation of Sprinkler Systems. | |||
| Facility:
Pearls Eden for Elders
Princeton, MO 60-Bed Skilled Nursing Facility Date of Notice: August 2008 |
Owner: Bagley,
Roger and Judy
Operator: Pearls II Eden for Elders Registered Agent: Robert C. Bagley |
Legal Action:
Uncorrected Class II Notice of Noncompliance In a letter from DHSS: On 12/02/2008, SLCR staff completed a revisit at the facility and determined that the Class I deficiency could be lowered to a Class II.
|
| Description: At the revisit on 7/18/2008, the facility failed to: To keep weeds and grass cut around the facility grounds and failed to appropriately store items outside the facility. To clean soiled toilets in resident bathrooms and shower rooms; to assure the facility was free from odors; to clean air conditioner vents and used duct tape to seal around the air conditioners; to maintain one shower room free from food; and, to maintain floors clean and in good repair. To assure a medication error rate of less than five percent. There were three errors with 40 opportunities for error, resulting in an error rate of 7.5%. To ensure staff accepted and released medications in a manner according to the facility’s policies; to ensure staff properly dated ophthalmic (eye) medications when they opened the medications; to discard the medications in a timely manner according to facility policy and manufacturer’s recommendation; and to ensure one medication was properly labeled. To ensure staff followed physician orders and to ensure staff used proper technique for the administration of ophthalmic eye drops/ointment. To assure staff practiced acceptable infection control measures when staff performed a blood glucose test. To provide maintenance and follow manufacturer recommendations to clean the oxygen concentrators and nebulizers (an electric machine used to deliver medication to the lungs by aerosol inhalation). To monitor and put interventions in place when one sampled resident had a 9.7% weight loss in two weeks. To maintain a safe environment when staff stored hazardous chemicals in unlocked cabinets/shower rooms accessible to residents. To provide effective pest control in resident rooms and living areas throughout the facility. | ||
| Facility:
Apple Ridge Care Center
Waverly, MO 60-Bed Skilled Nursing Facility Date of Notice: August 2008 |
Owner:
Riverview Heights Co.
Operator: Waverly #1, Inc. Registered Agent: Clifton Shirrell |
Legal Action:
Class I Notice of Noncompliance In a letter from DHSS: On 8/14/2008, SLCR staff completed a revisit at the facility and determined that the Class I deficiency could be lowered to a Class II.
|
| Description: The facility staff failed to provide for a safe environment, adequate assessment, adequate protective oversight and supervision, and did not follow the facility’s suicide precautions policy for one of three sampled residents (Resident #1) with a history of suicidal ideation and previous suicide attempts who made ongoing suicidal statements he/she was going to kill himself/herself and whom (sic) attempted to hang himself/herself with a rope from his/her bathroom door on 7/23/08. Staff failed to appropriately monitor and provide for the proper level of supervision needed for the resident who on 7/23/08, had just been moved to the facility’s locked Behavior Unit due to the resident’s increased symptoms of agitation and ongoing suicidal statements verbalized within the 24 hours prior to his/her suicide attempt. Staff had left the resident alone in his/her new room and did not complete an advance search of the resident’s new room to look for harmful objects prior to the resident’s transfer to his/her new room. Therefore, it was unknown to staff the resident got a hold of his/her roommate’s exercise rope, which he/she used to hang himself/herself. When staff found the resident hanging by the rope, emergency procedures were put in place, an ambulance was called to the facility, and the resident was transferred to a local hospital. The resident then had to be sent by helicopter to a second hospital where he/she was placed on a ventilator (a mechanical device used for artificial ventilation of the lungs) and where he/she later died on 07/31/08 from the injuries sustained when he/she hung himself/herself. | ||
| Facility: Liberty
Terrace Healthcare & Rehab
Liberty, MO 143-Bed Skilled Nursing Facility Date of Notice: September 2008 |
Owner: Liberty Terrace
Healthcare & Rehab Center, LLC
Operator: Same Registered Agent: National Registered Agents, Inc. |
Legal Action: Uncorrected Class II Notice of Noncompliance |
| Description: SLCR staff completed a second revisit on 08/28/2008 and the facility remained out of compliance. The facility failed to: Ensure a staff person accompanied one resident taken to the hospital for tests to provide care as needed. The facility failed to follow the plan of correction for the statement of deficiencies dated 07/03/2008. Staff did not follow physician orders and obtain laboratory tests for two residents. The facility census was 104 residents. | ||
| Facility: Valley
Manor & Rehab Center
Excelsior Springs, MO 120-Bed Skilled Nursing Facility Date of Notice: September 2008 |
Owner: Excelsior Real
Estate LLC
Operator: Excelsior Springs #1, Inc. Registered Agent: Not Listed |
Legal Action: Uncorrected Class II Notice of Noncompliance |
| Description: SLCR completed an annual inspection on 06/24/2008 and the facility was not in substantial compliance. At the revisit on 08/21/2008, the facility was still not in substantial compliance. The facility failed to have a medication error rate of lower than 5%. Observation showed the facility had a medication error rate of 6.9%. | ||
| Facility: Sunrise
on Clayton
Richmond, MO 90-Bed Intermediate Care Facility Date of Notice: September 2008 |
Owner: HCP Sun 2 Richmond
Heights, MO LLC
Operator: Sunrise Senior Living Management, Inc. Registered Agent: C T Corporation System |
Legal Action: Class I Notice of Noncompliance |
| Description: Based on observation, interview and record review, the facility failed to provide protective oversight and supervision for two residents (Resident #1 and Resident #2), with dementia and histories of wandering behaviors, who both left the facility without supervision. Resident #1 left the facility’s third-floor secured unit for residents with dementia, and the resident left the facility premises undetected by staff. Facility staff were unaware of the resident’s location until the resident’s family contacted the facility to notify them that the resident was at their home, at least four miles away from the facility. Resident #2 was left outside unattended by facility staff on the front porch, and the resident entered a parked, unlocked car on the parking lot. The census was 83. | ||
| Facility: Nodaway
Nursing Home
Maryville, MO 60-Bed Skilled Nursing Facility Date of Notice: September 2008 |
Owner: Nodaway County
Commission
Operator: Tiffany Care Centers, Inc. Registered Agent: David Duncan |
Legal Action: Uncorrected Class II Notice of Noncompliance |
| Description: A second revisit was completed on 09/16/2008 and the facility continued to be out of compliance. The facility failed to follow the plan of correction for the 07/01/2008 revisit and failed to follow facility protocol for prevention of constipation for three residents. The facility failed to ensure the residents who went longer than three days without a bowel movement were provided appropriate treatment. The facility census was 47 residents. | ||
| Facility: Thomas
Residential Care Center
St. Joseph, MO 16-Bed Residential Care Facility Date of Notice: October 2008 |
Owner: Jerry M. Strong
& Terry A. Strong
Operator: TAS Care, Inc. Registered Agent: Terry Strong |
Legal Action: Uncorrected Class II Notice of Noncompliance |
| Description: During the revisit on 09/19/2008, the facility remained out of compliance. The facility failed to ensure staff administered nebulizer (machine used to administer medications to improve breathing) treatments as prescribed by the physician and failed to follow manufacturer’s instructions for cleaning and disinfecting the nebulizer machines for two residents. The census was 16 residents. | ||
| Facility: Nodaway
Nursing Home
Maryville, MO 60-Bed Skilled Nursing Facility Date of Notice: October 2008 |
Owner: Nodaway County
Commission
Operator: Tiffany Care Centers, Inc. Registered Agent: David Duncan |
Legal Action: Uncorrected Class II Notice of Noncompliance |
| Description: Based on interview, and record review, the facility failed to ensure licensed nursing staff during the evening shift on 10/10/08, were knowledgeable about the medical condition for one resident (Resident #36), and failed to assess and provide appropriate treatment when the resident had an episode of respiratory distress and vomiting on 10/10/08. The charge nurse did not know whether the care plan addressed Resident #36’s breathing problems and what to do for the resident when the resident had respiratory episodes. Licensed nursing staff did not assess the resident’s breath sounds anytime during the resident’s respiratory episode. The facility failed to notify the resident’s physician, the resident’s family, and hospice about the resident’s respiratory and vomiting episode. The facility also failed to update Resident #36’s care plan to include parameters for when staff were to administer Mucomyst (medication used for inhalation, used for patients who have thick mucus secretions), or when staff were to administer Albuterol (inhaled medication used to relax muscles in the airways and increase air flow to the lungs) and Atrovent (inhaled medication used to treat narrowing airways in the lungs), when the resident’s oxygen saturation (measure of how much oxygen the blood is carrying as a percentage of the maximum it could carry) was compromised. The facility census was 43. | ||
| Facility: Ashton
Court Care & Rehab Center
Liberty, MO 140-Bed Skilled Nursing Facility Date of Notice: October 2008 |
Owner: Diamond Senior
Living
Operator: Ashton Court HealthCare, LLC Registered Agent: CSC Lawyers Incorporating Service Company |
Legal Action: Uncorrected Class II Notice of Noncompliance |
| Description: At the revisit on 09/19/2008, the facility remained out of compliance. The facility failed to assure staff monitored two residents’ blood sugar levels and failed to provide appropriate interventions when the resident’s blood sugar fell below normal levels and became symptomatic. The facility identified 31 diabetic residents resided in the facility. The facility census was 124 residents. | ||
| Facility: Ashton
Court Care & Rehab Center
Liberty, MO 140-Bed Skilled Nursing Facility Date of Notice: December 2008 |
Owner: Diamond Senior
Living
Operator: Ashton Court Health Care, LLC Registered Agent: CSC-Lawyers Incorporation Service |
Legal Action: Uncorrected Class II Notice of Noncompliance |
| Description: During the second revisit on 11/06/2008, the facility failed to provide supervision and care for one resident. Staff placed a blow dryer on Resident #61’s abdomen to warm the resident that resulted in burns. The facility census was 113. | ||
| Facility: Pearls
II Eden for Elders
Princeton, MO 60-Bed Skilled Nursing Facility Date of Notice: December 2008 |
Owner: Bagley, Roger &
Judy
Operator: Pearls II Eden for Elders Registered Agent: Roger C. Bagley |
Legal Action: Class I
Notice of Noncompliance In a letter from DHSS: On 12/02/2008, SLCR staff completed a revisit at the facility and determined that the Class I deficiency could be lowered to a Class II.
|
| Description: Facility staff failed to follow physician orders to transfer one resident with a mechanical lift. When the mechanical lift malfunctioned, staff notified the director of nursing who said to manually transfer the resident with a gait belt and two staff. During the transfer, the staff was unable to get the resident into his/her wheelchair and the resident’s knee hit the floor. Upon transfer to the emergency room, the physician diagnosed the resident with a fractured left femur and required surgery to repair the fracture. | ||
| Facility: Shady
Lawn Nursing Home
Savannah, MO 88-Bed Skilled Nursing Facility Date of Notice: December 2008 |
Owner: Andrew County
Nursing Home District
Operator: The Progressive Health Care Group, Inc. Registered Agent: James Lincoln |
Legal Action: Uncorrected Class II Notice of Noncompliance |
| Description: At the 11/18/2008 revisit the facility had not achieved compliance in the following areas: Fire Safety Standards as facility staff failed to know where to take residents during a fire, to call the fire department during a fire, where to assemble residents during an outside building evacuation and failed to know the location of manual fire alarm pull stations. Physical Plant Requirements as the facility failed to provide documentation to show they had conducted all inspections/testing of their water storage tank for the automatic fire sprinkler system. In addition, the facility failed to provide an accessible manual activation device for the kitchen range hood extinguishing system in the event of a fire and in a path of exit from the kitchen. The facility census was 43. | ||
| Facility:
Kendallwood Retirement Apts.
Gladstone, MO 100-Bed Residential Care Facility Date of Notice: December 2008 |
Owner: Kendallwood Senior
Properties, LLC
Operator: United Resource Management, LLC Registered Agent: Timothy J. Fisher |
Legal Action: Uncorrected Class II Notice of Noncompliance |
| Description: An inspection was completed on 10/10/2008. A revisit was completed on 12/05/2008 and the facility staff failed to ensure: Staff administered two residents the correct amount of insulin; that staff did not administer one resident expired insulin; that staff documented the correct amount of medication administered to two residents, and staff failed to ensure during medication administration that one resident took the medication. The facility census was 47. | ||
| Facility: Gower
Convalescent Center
Gower, MO 82-Bed Skilled Nursing Facility Date of Notice: December 2008 |
Owner: Gower Convalescent
Center, Inc.
Operator: Same Registered Agent: Paul E. Pottier |
Legal Action: Class I Notice of Noncompliance |
| Description: The facility had identified one resident (Resident #18) as a high fall risk. The care plan directed two staff were to transfer the resident with the use of a gait belt. On 10/29/2008, a certified nurse aide (CNA) attempted to transfer the resident without assistance of another staff person and without the use of a gait belt. The resident fell to the floor and x-rays showed the resident had a fractured hip. Due to preexisting health conditions, the resident was not a candidate for surgical repair of the fractured hip. The resident died on 11/04/08 and the resident’s physician said the result of the fall made the resident more debilitated and could have contributed to the resident’s death. The CNA said he/she knew that two staff were needed to transfer the resident but was “pressed for time” and attempted to transfer the resident by himself/herself. | ||
|
SOUTHEAST REGION | ||
| Facility: Holiday Residential Care
Perryville, MO 20-Bed Residential Care Facility Date of Notice: January 2008 |
Owner: B &
H Properties, LLC
Operator: Mkalma, LLC Registered Agent: Dorothy S. Terbrak |
Legal Action: Uncorrected Class II Notice of Noncompliance |
| Description: The facility failed to ensure the facility had the proper personnel to administer a supplemental feeding via the gastrostomy tube (g-tube), a tube placed through the abdominal wall into the stomach to provide feeding, for one resident. | ||
| Facility:
Essex Residential Care
Essex, MO 50-Bed Assisted Living Facility Date of Notice: January 2008 |
Owner: Theodore
Elliott
Operator: Theodore Elliott Registered Agent: Not Listed |
Legal Action: Class I Notice of Noncompliance |
| Description: A complaint investigation and licensure inspection was completed at the facility on 1/11/08. The facility was not in compliance with participation requirements. Facility staff failed to ensure adequate oversight and supervision of three residents, who left the facility without staff knowledge and were picked up by law enforcement. In addition the facility failed to ensure a staff did not physically or mentally abuse one resident even after the resident reported the abuse to another staff. The facility staff did not have documentation or evidence to support the resident’s allegation was investigated until the police returned the resident to the facility and made contact with the administrator to inform him of the resident’s allegations of abuse, which were verified by an anonymous person and two witnesses. Based on the facility compliance history and the severity of the violations a recommendation to revoke the facility license has been made. | ||
| Facility:
Heritage Hills
Patton, MO 24-Bed Assisted Living Facility Date of Notice: March 2008 |
Owner: Reed
& Reed Holdings LP
Operator: Reed & Reed Investments, Inc. Registered Agent: Melissa Reed |
Legal Action: Class I Notice of Noncompliance |
| Description: The facility failed to correct the trouble indicator lights on the fire alarm panel upon discovery. The fire alarm panel monitors a two-story building that consists of sheet-rocked walls, a shingled roof, and an exterior constructed of brick and siding. This citation has the potential to affect all residents in the facility. Facility census was 13. | ||
| Facility:
Partners Residential Care Center
Poplar Bluff, MO 18-Bed Residential Care Facility Date of Notice: May 2008 |
Owner:
Randolph, Carroll & Karen
Operator: Partners Residential Care Center, Inc. Registered Agent: Carroll L. Randolph |
Legal Action:
Class I Notice of Noncompliance In a letter from DHSS: On 6/03/2008, SLCR staff completed a revisit at the facility and determined that the Class I deficiency could be lowered to a Class II.
|
| Description: The facility failed to maintain the fire alarm system including the connection by telephone line to notify a monitoring company or fire department in the event of fire. The facility owner knowingly acted in a manner that would adversely affect the health, safety, welfare or property of residents by disabling part of the fire alarm system. | ||
| Facility:
Country View Residential Care
Gideon, MO 12-Bed Residential Care Facility Date of Notice: June 2008 |
Owner:
Randolph, Carroll & Karen
Operator: Randolph Carroll L. Registered Agent: Not Listed |
Legal Action: Class I and Uncorrected Class II Notice of Noncompliance |
| Description: The facility failed to have the proper staff on duty at all times. The facility failed to follow physicians’ orders for seven of eight sampled residents. | ||
| Facility:
Sunshine Villa
Scott City, MO 20-Bed Assisted Living Facility Date of Notice: June 2008 |
Owner:
McCulley, Ronald
Operator: Same Registered Agent: Not Listed |
Legal Action:
Class I Notice of Noncompliance In a letter from DHSS: On 6/06/2008, SLCR staff completed a revisit at the facility and determined that the Class I deficiency could be lowered to a Class II.
|
| Description: The facility failed to maintain the fire alarm system in proper working condition by silencing and not resetting the system after it went to alarm. | ||
| Facility:
Jefferson Manor
Cape Girardeau, MO 10-Bed Residential Care Facility Date of Notice: July 2008 |
Owner:
McCulley, Betty, Ronald and Atkinson
Operator: Sharon Armour Registered Agent: Not Listed |
Legal Action:
Uncorrected Class II Notice of Noncompliance In a letter from DHSS: On 5/28/2008, SLCR staff completed a revisit at the facility and determined that the Class I deficiency could be lowered to a Class II.
|
| Description: The facility failed to continue to act in a manner that would ensure the safety and welfare of all eight residents. The facility failed to continue to provide protective oversight for all eight residents by allowing Employee A to continually reside and work in the facility. | ||
| Facility:
Country Gardens
Cape Girardeau 56-Bed Assisted Living Facility Date of Notice: August 2008 |
Owner: Sample,
Johnnie and Tomi
Operator: Country Gardens, Inc. Registered Agent: Patricia J. Launius |
Legal Action: Uncorrected Class II Notice of Noncompliance |
| Description: The facility failed to obtain a sufficient bond one and one-half times the average monthly balance of the residents’ personal funds. Record review revealed the average monthly balance of $20,783.29 for the resident fund account. Further review revealed the approved bond amount of $18,000 which is not at least one and one-half (1 ½) times the average monthly balance of the residents’ personal funds. | ||
| Facility:
Hilda Fuwells Residential Care Facility
Dexter, MO 20-Bed Residential Care Facility Date of Notice: August 2008 |
Owner: Not
Listed
Operator: Hilda Fuwells Residential Care LLC Registered Agent: Hilda Fuwell |
Legal Action: Uncorrected Class II Notice of Noncompliance |
| Description: The facility failed to bring the residents’ fund accounts current each month. | ||
| Facility:
Sells Rest Home
Matthews, MO 94-Bed Skilled Nursing Facility Date of Notice: August 2008 |
Owner: Sells
Rest Home, Inc.
Operator: Close to Home, Inc. Registered Agent: John M. Sells |
Legal Action:
Class I Notice of Noncompliance In a letter from DHSS: On 8/01/2008, SLCR staff completed a revisit at the facility and determined that the Class I deficiency could be lowered to a Class II.
|
| Description: The facility failed to provide protective oversight and supervision for five residents. | ||
| Facility: Sells
Rest Home
Matthews, MO 94-Bed Skilled Nursing Facility Date of Notice: September 2008 |
Owner: Sells Rest Home,
Inc.
Operator: Close to Home, Inc. Registered Agent: John M. Sells |
Legal Action: Uncorrected Class II Notice of Noncompliance |
| Description: The facility failed to ensure all resident funds in excess of $50 were placed in an interest bearing account, separate from the facility operating account. The facility failed to obtain authorizations from 49 sampled residents for cash withdrawals from the residents trust fund account. The facility failed to ensure five sampled residents had sufficient funds to cover withdrawals from the resident trust fund account. The facility failed to maintain all written accounts of resident’s funds and reconcile them monthly. The facility failed to notify residents who receive Medicaid benefits that they were within $200 of their Supplemental Security Income (SSI) resource limit. The facility failed to send residents and/or their responsible parties a quarterly accounting of each resident’s trust fund account. | ||
| Facility: Essex
Residential Care
Essex, MO 50-Bed Assisted Living Facility Date of Notice: October 2008 |
Owner: Theodore A.
Elliott
Operator: Same Registered Agent: Not Listed |
Legal Action: Class I Notice of Noncompliance |
| Description: The facility failed to provide twenty-four hour protective oversight for two residents. | ||
| Facility: J &
J Assisted Living
Marble Hill, MO 12-Bed Residential Care Facility Date of Notice: December 2008 |
Owner: Mary E. Long Living
Trust Agreement
Operator: Jon C. Pierce Registered Agent: Not Listed |
Legal Action: Uncorrected Class II Notice of Noncompliance |
| Description: The facility failed to obtain written authorization from residents in order to hold, safeguard, manage, and account for the residents’ personal funds. The facility failed to exclusively use the personal funds for residents only. The facility failed to maintain a bond one and one-half times the average monthly balance of the residents’ personal funds. | ||
| Facility: Baptist
Home
Ironton, MO 135-Bed Intermediate Care Facility Date of Notice: December 2008 |
Owner: The Baptist
Home
Operator: Same Registered Agent: Jim Shoemake |
Legal Action: Uncorrected Class II Notice of Noncompliance |
| Description: The facility failed to screen one resident out of five sampled residents and six other residents for tuberculosis. The facility failed to follow physician’s orders during administration of medications for two of six sampled residents and five additional residents. | ||
|
SOUTHWEST REGION | ||
| Facility: Sikeston Health Care
Sikeston, MO 100-Bed Skilled Nursing Facility Date of Notice: January 2008 |
Owner: Twilight
Haven Rest Home, Inc.
Operator: N & R Sikeston Health Care, Inc. Registered Agent: None |
Legal Action: Class I Notice of Noncompliance |
| Description: An interim inspection was completed on 1/3/2008 and the facility was not in substantial compliance. Conditions in the facility constituted immediate jeopardy in the area of fire safety. The fire alarm panel showed two illuminated warning lights indicating a problem with the fire alarm system. One of the warning lights indicated staff had silenced the fire alarm. The facility failed to notify the Department that the fire alarm was out of service for more than four hours and failed to implement a fire watch until the fire alarm was found to be fully functional. | ||
| Facility:
Northwood Hills Care Center
Humansville, MO 120-Bed Skilled Nursing Facility Date of Notice: March 2008 |
Owner: Medical
Investments, LL
Operator: Northwood Hills Care Center, LLC Registered: C T Corporation System |
Legal Action: Uncorrected Class II Notice of Noncompliance |
| Description: The facility failed to provide appropriate incontinence care for one resident. The resident had a history of skin breakdown. | ||
| Facility:
Christian Health Care of Springfield East
Springfield, MO 120-Bed Skilled Nursing Facility Date of Notice: March 2008 |
Owner: Not
Listed
Operator: Christian Health Care of Springfield East, Inc. Registered Agent: Pete Stayton |
Legal Action: Class I Notice of Noncompliance |
| Description: The facility failed to notify the physician of abnormal vital signs and foul smelling emesis during the night shift beginning at 11:00 p.m. on 2/16/2008; failed to provide follow up assessments of concerns identified by a direct care staff and failed to provide appropriate nursing interventions to address the discomfort of one resident (Resident #1) who died on 2/17/2008 at 7:20 a.m. in the facility. The facility census was 116. | ||
| Facility:
Autumn Place Residential Care of Joplin
Joplin, MO 38-Bed Residential Care Facility Date of Notice: March 2008 |
Owner: Autumn
Home Care Facilities, Inc.
Operator: Same Registered Agent: Barney Forbes |
Legal Action: Uncorrected Class II Notice of Noncompliance |
| Description: The facility failed to post cautionary oxygen signs on or near the door of one resident who used an oxygen concentrator. The facility failed to ensure all electrical adaptors were used in a safe manner in two residents’ rooms to prevent the potential of a fire hazard. The facility failed to ensure the hot water temperature for a sink in a common-use handicapped accessible bathroom was below 120 degrees Fahrenheit. The hot water temperature measured 126.6 degrees Fahrenheit, and the cold water temperature measured 126 degrees Fahrenheit. The facility failed to establish a policy regarding emergency and life sustaining care and failed to review such policies and other health care advanced directives with residents or their representatives at admission and annually. | ||
| Facility:
Joy Assisted Living for Seniors
Springfield, MO 74-Bed Assisted Living Facility Date of Notice: March 2008 |
Owner: Edmonds,
Kenneth & Joy
Operator: Joyco Incorporated Registered Agent: Not Listed |
Legal Action: Uncorrected Class II Notice of Noncompliance |
| Description: The facility failed to ensure no part of the building presented a fire hazard when one out of nine current residents who use oxygen (Resident #5) had unsecured oxygen cylinders in the room. | ||
| Facility:
Sunnyhills Residential Care Facility
Carthage, MO 18-Bed Residential Care Facility Date of Notice: March 2008 |
Owner: Farley,
Philip O and Rowena
Operator: Farley’s, Inc. Registered Agent: Philip O. Farley |
Legal Action: Uncorrected Class II Notice of Noncompliance |
| Description: A licensure inspection was completed on 12/07/07. The facility was not in compliance with participation requirements. A revisit was completed on 3/21/08. The facility failed to ensure a safe and effective medication system for properly storing and administering multi dose vials of insulin. Facility staff used outdated insulin for one diabetic resident. The manufacturer recommendations revealed a vial of insulin which had been entered and used for 28 days must be discarded. | ||
| Facility:
NHC Healthcare, West Plains
West Plains, MO 120-Bed Skilled Nursing Facility Date of Notice: March 2008 |
Owner: National
Health Realty LLC
Operator: NHC Healthcare/West Plains, LLC Registered Agent: National Registered Agents, Inc. |
Legal Action:
Class I Notice of Noncompliance In a letter from DHSS: On 3/24/2008, SLCR staff completed a revisit at the facility and determined that the Class I deficiency could be lowered to a Class II.
|
| Description: The facility failed to provide protective oversight and ensure four residents were free from mental and sexual abuse from one resident. The facility administrative staff failed ensure (sic) staff reported and investigated the incidents to provide protective oversight to all residents. | ||
| Facility:
Whispering Hills, LLC
Eldorado Springs, MO 14-Bed Residential Care Facility Date of Notice: March 2008 |
Owner: Not
Listed (Not Licensed)
Operator: Not Listed (Not Licensed) Registered Agent: Not Listed |
Legal Action: DENIAL OF LICENSURE APPLICATION |
| Description: This decision is based on the following grounds, which, individually, are sufficient to deny your application for licensure, and in combination, are abundantly sufficient to deny your application: The operator or any principals in the operation of the facility have ever knowingly acted or knowingly failed to perform any duty which materially and adversely affected the health, safety, welfare or property of a resident, while acting in a management capacity. (See Section 198.022.5, RSMo). The operator has failed to provide a complete application, including all required attachments, demonstrating financial capacity to operate the facility. (See Section 198.022.1(3), RSMo). All fees due to the state have not been paid. (Section 198.022.7, RSMo). | ||
| Facility:
Essex of Lebanon
Lebanon, MO 12-Bed Residential Care Facility Date of Notice: April 2008 |
Owner: Bristol
Care, Inc.
Operator: Bristol Care, Inc. Registered Agent: David C. Furnell |
Legal Action: Uncorrected Class II Notice of Noncompliance |
| Description: A licensure inspection was completed 12/04/07. The facility was not in compliance with participation requirements. A revisit was performed on 3/27/08. The facility failed to take action to comply with state statute and obtain a license with Department of Mental Health when providing care to a resident with diagnosis of mental retardation or mental illness. | ||
| Facility:
Bristol Manor of Lamar
Lamar, MO 12-Bed Residential Care Facility Date of Notice: April 2008 |
Owner: Bristol
Care, Inc.
Operator: Same Registered Agent: David C. Furnell |
Legal Action: Uncorrected Class II Notice of Noncompliance |
| Description: A licensure inspection was completed on 2/06/08. The facility was not in substantial compliance with participation requirements. A revisit was completed on 4/02/08. The facility failed to assure compliance with all applicable laws and regulations by obtaining a license with Department of Mental Health when providing care to a resident with diagnosis of mental retardation. | ||
| Facility:
Joe Clark Residential Care Home
Nevada, MO 22-Bed Residential Care Facility Date of Notice: April 2008 |
Owner: Barry G.
Clark
Operator: Clark Health Care, Inc. Registered Agent: Barry G. Clark |
Legal Action: Class I Notice of Noncompliance |
| Description: A licensure inspection and complaint investigation was completed on 4/04/08. The facility was not in substantial compliance with participation requirements. The facility failed to: Maintain the sprinkler system in accordance with the National Fire Protection Association. Make immediate corrections and repairs to the fire alarm system when staff discovered it was non-functioning on 3/14/08. To immediately implement a 24-hour fire watch to ensure the safety of residents until advised to do so by the local fire department on 3/13/08 (17 days later). Ensure that no person shall commit a knowing act that would adversely affect the health, safety, welfare or property of residents when the owner/administrator failed to repair the fire alarm/sprinkler system, failed to release funds to the manager to provide for food, needed repairs to the facility, provide needed trash service and provide activities. | ||
| Facility:
Silver Oak Senior Living of Nevada
Nevada, MO 57-Bed Residential Care Facility Date of Notice: April 2008 |
Owner: NHP SH
Missouri LLC
Operator: Silver Oak Senior Living Management Co., LC Registered Agent: Ken Hanne |
Legal Action: Class I Notice of Noncompliance |
| Description: A complaint investigation was completed on 4/15/08. The facility was not in compliance with participation requirements. The facility failed to ensure one who suffered from Post Traumatic Stress Disorder and Autism was free from mental abuse and involuntary seclusion. Facility staff failed to allow the resident to leave his/her room or attend activities when he/she complained of feeling ill and did not go to work. | ||
| Facility:
Plantation Manor
Bolivar, MO 16-Bed Residential Care Facility Date of Notice: May 2008 |
Owner:
McPheeters, Hobart & Ann
Operator: Lighthouse of Hope, LLC Registered Agent: Christie Aman |
Legal Action: Class I Notice of Noncompliance |
| Description: A licensure inspection was completed on 3/11/08. The facility was not in substantial compliance with participation requirements. A revisit was completed on 5/07/08. The facility failed to ensure no portion of the building presented a fire hazard when storing combustible material in the attic, with wooden trusses that were not protected and electrical junction boxes were uncovered. The electrical wiring was visible in the junction box and revealed wires taped together with electrical tape instead of being capped. The facility does not have a sprinkler system. Additionally, Class II deficiencies not corrected included the following: Facility staff failed to ensure hazardous areas were separated by one hour fire resistant rating in the boiler room. Facility staff failed to have an electrical inspection completed by a qualified electrician. | ||
| Facility:
NHC Healthcare, West Plains
West Plains, MO 120-Bed Skilled Nursing Facility Date of Notice: May 2008 |
Owner: NHC
Healthcare/West Plains LLC
Operator: Same Registered Agent: National Registered Agents, Inc. |
Legal Action:
Class I Notice of Noncompliance In a letter from DHSS: On 5/15/2008, SLCR staff completed a revisit at the facility and determined that the Class I deficiency could be lowered to a Class II.
|
| Description: A revisit was completed on 4/30/08. The facility was not in substantial compliance with participation requirements. The facility failed to provide care and services for a resident who displayed mental psychosocial adjustment difficulty. The facility failed to develop and implement interventions to address the resident’s escalating behaviors, monitor and obtain needed services for one resident who exhibited aggressive threatening behaviors towards self, other residents and staff by verbally and physically assaulting other residents and made threats of suicide. | ||
| Facility:
Glendale Gardens
Clinton, MO 42-Bed Assisted Living Facility Date of Notice: May 2008 |
Owner: Clinton
Residential, LLC
Operator: Same Registered Agent: Husch Registered Agent, Inc. |
Legal Action: Class I Notice of Noncompliance |
| Description: An interim inspection was completed on 5/14/08. The facility was not in substantial compliance with participation requirements. The facility staff failed to maintain the hot water temperature below a 120 degrees Fahrenheit. The hot water temperature in the common-use bathroom and assisted shower room measured 141.6 degrees F and 142 degrees F. The facility had eight residents with a diagnosis of Alzheimer’s disease and six residents with diagnosis of diabetes, who had access to both rooms. | ||
| Facility:
Tablerock Healthcare
Kimberling City, MO 120-Bed Skilled Nursing Facility Date of Notice: May 2008 |
Owner: Al
Schluter
Operator: Kindred Nursing Centers East, LLC Registered Agent: C T Corporation System |
Legal Action: Class I Notice of Noncompliance |
| Description: A complaint investigation was completed on 5/05/08. The facility was not in substantial compliance with participation requirements. The facility staff failed to assess, monitor and obtain appropriate medical services for one resident who had an acute significant change in condition and required hospitalization due to a stroke. On 4/04/08 staff noted a change in the resident’s condition and notified the resident’s physician. The physician ordered the resident to be sent to the hospital for evaluation and treatment. Facility staff called for an ambulance and when it arrived at 12:30 p.m., the Director of Nurses cancelled sending the resident to the hospital. At 7:00 p.m., the staff contacted the physician regarding the resident’s condition and the physician ordered the resident be sent out to the hospital for evaluation and treatment. The resident was diagnosed with a stroke and was hospitalized. | ||
| Facility:
Countryside Home
Lebanon, MO 20-Bed Residential Care Facility Date of Notice: May 2008 |
Owner: Theodore
& Velma Maydew
Revocable Operator: Velma Maydew Registered Agent: Not Listed |
Legal Action: Class I Notice of Noncompliance |
| Description: A licensure inspection and complaint investigation was completed at the facility on 4/23/08. The facility was not in substantial compliance with participation requirements. The facility staff failed to not admit or continue to care for residents whose needs cannot be met. The facility admitted one resident directly from the hospital without knowledge of the resident’s history or diagnoses. The staff stated they felt sorry for the resident and they made a mistake admitting him/her. The resident exhibited harmful behaviors to self and others, which included threatening to slap two other residents and two elopements on 4/19/08 and 4/20/08. | ||
| Facility:
Magnolia Square Nursing and Rehab Center
Springfield, MO 120-Bed Skilled Nursing Facility Date of Notice: May 2008 |
Owner:
Springfield Care Center, LLC
Operator: Magnolia Square Nursing and Rehab Center LLC Registered Agent: National Registered Agent |
Legal Action:
Class I Notice of Noncompliance In a letter from DHSS: On 5/23/2008, SLCR staff completed a revisit at the facility and determined that the Class I deficiency could be lowered to a Class II.
|
| Description: A complaint investigation was completed on 5/09/08. The facility was not in substantial compliance with participation requirements. The facility failed to provide adequate supervision and assistive devices to prevent accidents. The facility staff failed to develop and implement interventions to address one resident’s choking or aspiration risk and provide supervision during meals. The resident expired on 4/26/08. | ||
| Facility:
Big Spring Care Center
Humansville, MO 60-Bed Skilled Nursing Facility Date of Notice: June 2008 |
Owner:
Deaconess Long Term Care of Missouri
Operator: Same Registered Agent: The Corporation Company |
Legal Action:
Class I Notice of Noncompliance In a letter from DHSS: On 6/25/2008, SLCR staff completed a revisit at the facility and determined that the Class I deficiency could be lowered to a Class II.
|
| Description: The facility failed to monitor and implement interventions to protect at least two residents (Resident #5 and #13) from sexual assault perpetrated by one resident (Resident #12). | ||
| Facility:
Point Lookout Nursing & Rehab
Hollister, MO 130-Bed Skilled Nursing Facility Date of Notice: June 2008 |
Owner: Lortoy,
Inc.
Operator: N & R of Hollister, LLC Registered Agent: Charlotte Stutts |
Legal Action: Class I Notice of Noncompliance |
| Description: The facility failed to prevent the development of multiple Stage III and two unstageable pressure ulcers for one resident. The facility failed to reposition and provide pressure-relieving devices, failed to assess and implement nutritional interventions to promote healing, failed to obtain treatment orders for all of the pressure ulcers and failed to notify the physician of worsening of the pressure ulcers. As of 6/6/08, the nurse practitioner for the resident’s physician identified one unstageable pressure ulcer on the left heel, three Stage III pressure ulcers on the left foot and an unstageable pressure ulcer with deep tissue injury on the right heel. | ||
| Facility:
Webco Manor
Marshfield, MO 120-Bed Skilled Nursing Facility Date of Notice: June 2008 |
Owner: Webster
County Nursing Home District, Inc.
Operator: Same Registered Agent: Cathy Rust |
Legal Action:
Class I Notice of Noncompliance In a letter from DHSS: On 6/11/2008, SLCR staff completed a revisit at the facility and determined that the Class I deficiency could be lowered to a Class II.
|
| Description: A survey was completed on 5/27/08. The facility was not in substantial compliance with participation requirements. The facility staff failed to initiate cardiopulmonary resuscitation for one resident who became unresponsive and expired. The resident had a current physician order for full code status. In addition, the facility staff where (sic) unaware of other resident’s code status and did not know the policies, procedures and standard practices for care when an emergency situation arose. | ||
| Facility:
Webco East
Marshfield, MO 24-Bed Residential Care Facility Date of Notice: June 2008 |
Owner: Webster
County Nursing Home District, Inc.
Operator: Same Registered Agent: Jo Walker |
Legal Action: Class I Notice of Noncompliance |
| Description: The facility failed to ensure plumbing fixtures that are accessible to residents did not supply hot water in excess of 120 degrees Fahrenheit. During the annual licensure inspection, hot water temperatures in resident rooms and the public restroom ranged from 124.7 degrees to 146.7 degrees Fahrenheit. | ||
| Facility:
Manorcare Health Services
Springfield, MO 194-Bed Skilled Nursing Facility Date of Notice: July 2008 |
Owner: HCR
Manorcare Properties LLC
Operator: Manor Care of Springfield MO LLC Registered Agent: C T Corporation System |
Legal Action:
Class I Notice of Noncompliance In a letter from DHSS: On 7/18/2008, SLCR staff completed a revisit at the facility and determined that the Class I deficiency could be lowered to a Class II.
|
| Description: A survey was completed at the facility on 7/02/08. The facility was not in substantial compliance with participation requirements. The facility failed to provide adequate oversight and supervision of one resident, with a history of sexually inappropriate behavior, from touching other confused residents inappropriately. The facility staff failed to monitor and develop interventions to protect at least three residents from sexually inappropriate behavior perpetrated by one resident. Also the facility failed to protect four residents from physical abuse perpetrated by two residents. | ||
| Facility:
Cedar Ridge Care Center
Cassville, MO 30-Bed Residential Care Facility Date of Notice: July 2008 |
Owner: Long,
Michael & Roswitha
Operator: M & R Long, Inc. Registered Agent: Lisa McKay |
Legal Action: Class I Notice of Noncompliance |
| Description: A complaint investigation was completed on 7/17/08. The facility was not in substantial compliance with participation requirements. The facility failed to provide proper care to meet the needs of one resident. The facility staff failed to assess, monitor and/or seek medical care for one resident, who fell and sustained a facial fracture and extensive facial swelling and bruising. Staff failed to notify the resident’s physician, guardian or facility management in accordance with facility policy and procedures. | ||
| Facility:
NHC of West Plains
West Plains, MO 120-Bed Skilled Nursing Facility Date of Notice: August 2008 |
Owner: NHC
Healthcare/West Plains, LLC
Operator: Same Registered Agent: National Registered Agents, Inc. |
Legal Action: Class I Notice of Noncompliance |
| Description: A complaint investigation was completed on 7/31/08. The facility was not in substantial compliance with participation requirements. The facility failed to protect residents from physical, verbal and sexual abuse perpetrated by one resident with a known history of inappropriate sexual behavior. On 7/28/08 staff found the resident in another resident’s room attempting to sexually assault the other resident. | ||
| Facility:
Joe Clark Residential Care Home
Nevada, MO 22-Bed Residential Care Facility Date of Notice: August 2008 |
Owner: Barry G.
Clark
Operator: Clark Health Care, Inc. Registered Agent: Barry G. Clark |
Legal Action: Uncorrected Class II Notice of Noncompliance |
| Description: A licensure inspection was completed on 4/04/08. A revisit was completed on 7/22/08. The facility was not in substantial compliance with participation requirements. The facility failed to: develop a written plan for emergencies and evacuations; complete fire drills on all three shifts as required; maintain the building and grounds in good repair; provide a written statement of services provided by the facility and the charges for these services upon admission. | ||
| Facility:
Northview Manor
Tarkio, MO 95-Bed Skilled Nursing Facility Date of Notice: August 2008 |
Owner: SPTIHS
Properties Trust
Operator: Five Star Quality Care Registered Agent: CSC – Lawyers Incorporating Service |
Legal Action: Uncorrected Class II Notice of Noncompliance |
| Description: At the second revisit on 08/01/2008, the facility was still not in substantial compliance based on an uncorrected deficiency in the area of Administration and Resident Care Requirements. The facility failed to ensure staff followed the plan of care for four resident’s identified by staff at risk for and/or had a history of falls. Staff failed to provide adequate supervision, alarm placement and functioning, for one resident that had two avoidable falls on 7/5/08. Staff also failed to assure safety devices were in place and functioning for another resident to prevent falls. The facility failed to put in place interventions to keep Resident #16 from reocurring (sic) falls. The facility census was 42. | ||
| Facility:
Sonshine Manor
Republic, MO 31-Bed Skilled Nursing Facility Date of Notice: September 2008 |
Owner: N & R of
Southwest MO, LLC
Operator: N & R of Republic, LLC Registered Agent: Charlott Stutts |
Legal Action: Class I Notice of Noncompliance |
| Description: A licensure inspection was completed at the above facility on 8/18/08. The facility was not in substantial compliance with participation requirements. The facility failed to assess, monitor and implement interventions to address one resident’s pain control during treatment of a stage IV pressure sore. Facility staff failed to administer pain medication as directed by the resident’s physician. The resident had not received pain medication since 06/09/08, even though the resident cried out and was resistive to staff during treatments. | ||
| Facility:
Oakbrook Residence
Springfield, MO 21-Bed Residential Care Facility Date of Notice: September 2008 |
Owner: Barefoot Boy,
LLC Operator: Same Registered Agent: Rajab Echessa |
Legal Action: Class I Notice of Noncompliance |
| Description: A complaint investigation was completed on 8/26/08 and 09/04/08. The facility was not in substantial compliance with participation requirements. Also, the Operator was not in compliance with the Consent Agreement entered into with the Department of Health and Senior Services (DHSS) on 03/18/08. The facility failed to ensure staff were awake and prepared to assist residents on the night shift when at least 11 residents and two facility staff members found the Operator/Administrator, who worked the night shift, asleep on multiple occasions and unresponsive to the residents needs. The facility failed to provide adequate staffing to ensure 24 hours protective oversight when the Operator/Administrator left the facility while on duty at least three times (one time for at least 45 minutes) without other staff present in the building to monitor the welfare and safety of the residents. A visitor and resident contacted the previous Director of Nurses to inform him/her of no staff in the building when residents needed their medications. | ||
| Facility: Mercy
Villa
Springfield, MO 150-Bed Skilled Nursing Facility Date of Notice: September 2008 |
Owner: St. Johns Regional
Health Center
Operator: Same Registered Agent: Michael Merrigan |
Legal Action: Class I Notice of Noncompliance |
| Description: A complaint investigation was completed on 09/10/08. The facility was not in substantial compliance with participation requirements. The facility failed to: Assess, monitor, notify the physician and implement interventions for one resident who did not have a bowel movement for 11 days that resulted in a partial small bowel obstruction. The resident later died. Assess, monitor and notify the physician of another resident who had a seven pound weight gain in nine days, increased shortness of breath and swelling in the lower extremities which required hospitalization for pneumonia with sepsis (infection in the blood). | ||
| Facility: Crane
Residential Care Home
Crane, MO 28-Bed Residential Care Facility Date of Notice: September 2008 |
Owner: Davidson, Troy
III
Operator: TRDIII, Inc. Registered Agent: Troy Davidson III |
Legal Action: Uncorrected Class II Notice of Noncompliance |
| Description: A licensure inspection was completed on 7/31/08. The facility was not in substantial compliance with participation requirements. A revisit was completed on 09/09/08. The facility failed to ensure two employees completed a two-step tuberculosis test as required for long term care facilities. | ||
| Facility:
Lakeside Mountain Manor
Forsyth, MO 40-Bed Residential Care Facility Date of Notice: October 2008 |
Owner: Droll, John W. and
Debra J.
Operator: Lakeside Mountain Manor, LLC Registered Agent: Lisa McKay |
Legal Action: Class I Notice of Noncompliance |
| Description: A licensure inspection was completed on 10/08/08. The facility was not in compliance with participation requirements. The facility failed to: Ensure no section of the building presented a fire hazard when the owner installed a new breaker box in the laundry room, which was accessible to residents, with spliced wire not covered or in junction boxes. Ensure compliance with the fire safety standards in effect at the time of initial license issuance. Document tests of fire alarm system and fire drill records. Certify drapes or curtains were flame resistant or treated. Maintain compliance with National Electrical Code. Ensure proper use of extension cords and plug adapters. | ||
| Facility:
Ravenwood
Springfield, MO 51-Bed Assisted Living Facility Date of Notice: October 2008 |
Owner: Ravenwood
Residential, LLC
Operator: Same Registered Agent: Husch Registered Agent, Inc. |
Legal Action: Class I Notice of Noncompliance |
| Description: An annual licensure inspection was completed on 10/28/2008. The facility was not in substantial compliance with participation requirements. The facility failed to maintain hot water temperatures accessible to residents below 120 degrees Fahrenheit (F) in the common use bathroom and one resident room measured above 140 degrees F. The facility had ten residents with diagnosis of Alzheimer’s disease, six with mental illness diagnosis and three residents with diagnosis of diabetes. | ||
| Facility:
Mountain View Healthcare
Mountain View, MO 90-Bed Skilled Nursing Facility Date of Notice: December 2008 |
Owner: Willow Health Care,
Inc.
Operator: Same Registered Agent: Jack Whitaker |
Legal Action: Class I Notice of Noncompliance |
| Description: An annual survey was completed on 10/24/08. The facility was not in compliance with participation requirements. The facility failed to maintain the hot water temperatures within a safe range, not to exceed 120 degrees Fahrenheit, when six resident room hand sinks on the West halls and 12 resident hand sinks in the Special Care unit and one shower room with hot water temperatures between 123.5 to 140 degrees F. The facility staff were aware the hot water system had an engineering design defect when the system was installed several months ago. | ||
| Facility: Joy
Assisted Living for Seniors
Springfield, MO 74-Bed Assisted Living Facility Date of Notice: December 2008 |
Owner: Edmonds, Kenneth
& Joy
Operator: Joyco, Inc. Registered Agent: Thomas Peebles, Jr. |
Legal Action: Class I Notice of Noncompliance |
| Description: A licensure inspection was completed on 11/25/08. The facility was not in substantial compliance with participation requirements. The facility failed to maintain hot water temperatures below 120 degrees Fahrenheit (F), when the hot water temperature in the common use bathroom and beauty parlor measured between 125.3 degrees and 150.5 degrees F. | ||
| Facility:
Tablerock Healthcare
Kimberling City, MO 120-Bed Skilled Nursing Facility Date of Notice: December 2008 |
Owner: Schluter, Al
Operator: Kindered Nursing Centers East, LLC Registered Agent: C T Corporation System |
Legal Action: Class I Notice of Noncompliance |
| Description: An annual survey was conducted at the facility on 12/10/08. The facility was not in substantial compliance with participation requirements. The facility staff failed to assess, document, report, and initiate treatment for an unstageable wound to the right foot of one resident that subsequently produced purulent material when examined by the resident’s physician. In addition, the facility failed to identify and intervene in a pattern of chronic constipation for one resident. The resident subsequently developed fecal stasis and required surgery and the placement of a colostomy. | ||
|
ST. LOUIS REGION | ||
| Facility: Autumn Oaks Caring Center
Mountain Grove, MO 120-Bed Skilled Nursing Facility Date of Notice: January 2008 |
Owner: Mountain
Grove #1, Inc.
Operator: Mountain Grove #2, Inc. Registered Agent: Clifton L. Shirrell |
Legal Action: Uncorrected Class II Notice of Noncompliance |
| Description: A licensure inspection was completed on 11/16/07. The facility was not in substantial compliance with participation requirements. A revisit was completed on 12/14/07. The facility had failed to correct violations in the area of standards of practice and pressure sore prevention. Facility staff failed to discard opened multi-use vials of insulin and tuberculin beyond the date determined by the manufacturer as safe for use. The staff failed to provide adequate wound prevention interventions and/or assistive devices to prevent new wounds from developing for four of 16 sampled residents. | ||
| Facility:
St. Elizabeth Healthcare & Rehab Center
Florissant, MO 150-Bed Skilled Nursing Facility Date of Notice: January 2008 |
Owner: Not
Listed
Operator: St. Elizabeth Healthcare & Rehab Center LLC Registered Agent: Robin Suydam |
Legal Action: Uncorrected Class II Notice of Noncompliance |
| Description: A licensure inspection and complaint investigation was completed on 9/17/07. The facility was not in compliance with participation requirements. Revisits were completed on 11/15/07 and 1/07/08. The facility is not in substantial compliance with participation requirements. The facility failed to follow physician orders regarding the administration of medications and arranging an appointment with a specialist for one resident, ensure compression stockings were applied as directed by the resident’s physician and failed to document administration of one residents insulin. Additional violations were found and new deficiencies cited that had been previously corrected. | ||
| Facility:
Cedars at the JCA
Chesterfield, MO 230-Bed Skilled Nursing Facility Date of Notice: February 2008 |
Owner: Jewish
Center for Aged
Operator: Same Registered Agent: Not Listed |
Legal Action: Uncorrected Class II Notice of Noncompliance |
| Description: Complaint investigations were completed at the facility on 8/31/07, 10/30/07 and 12/05/07. The facility was not in substantial compliance with participation requirements. A revisit was completed on 1/18/08. The facility failed to take appropriate action to correct the following violations: Thoroughly investigate and report allegations of abuse and neglect for two residents to the State licensing agency. Facility staff failed to notify the resident’s physician of a possible allergic reaction to a new medication. The resident required admission to the hospital for treatment of the underlying condition and for the allergic reaction. Also, the facility failed to obtain prompt hospital evaluation for one resident who exhibited symptoms of a heart attack despite the family’s request. Facility staff failed to implement protective measures to prevent falls one resident, who fell from a bariatric lift and sustained a fractured leg and now requires antianxiety medication when transferred. Staff failed to develop and implement interventions for another resident with repeated falls. The facility failed to maintain a medication administration error rate of less than 5%. Out of 47 opportunities for error, there were eight errors observed. This yielded a medication administration error rate of 17.02%. | ||
| Facility:
Hillside Manor Healthcare and Rehab
St. Louis, MO 208-Bed Skilled Nursing Facility Date of Notice: February 2008 |
Owner: Hillside
Manor Properties, LLC
Operator: Hillside Manor Healthcare and Rehab Center, LLC Registered Agent: Robin Suydam |
Legal Action:
Class I Notice of Noncompliance In a letter from DHSS: On 2/06/2008, SLCR staff completed a revisit at the facility and determined that the Class I deficiency could be lowered to a Class II.
|
| Description: The facility failed to provide oversight and appropriate interventions for two cognitively impaired residents who were reported to have engaged in sexual activity and for one resident who engaged in sexual activity without consent of his/her legal guardian and who cut him/herself on two occasions. The residents resided on the behavior unit. | ||
| Facility:
Rancho Manor Healthcare & Rehab Center
Florissant, MO 120-Bed Skilled Nursing Facility Date of Notice: March 2008 |
Owner: Rancho
Manor Properties, LLC
Operator: Rancho Manor Healthcare and Rehabilitation Center, LLC Registered Agent: Robin Suydam |
Legal Action:
Class I Notice of Noncompliance In a letter from DHSS: On 4/03/2008, SLCR staff completed a revisit at the facility and determined that the Class I deficiency could be lowered to a Class II.
|
| Description: A complaint investigation was performed on 1/18/08. The facility was not in substantial compliance with participation requirements. A revisit and complaint investigation was completed on 3/19/08. The facility had failed follow (sic) acceptable medical practice and follow their own policy to institute cardiopulmonary resuscitation for two residents, who were found without pulse or respirations, who wished to have CPR performed under such circumstances resulting in the death of both residents. | ||
| Facility:
Grand Manor Nursing & Rehab Center
St. Louis, MO 120-Bed Skilled Nursing Facility Date of Notice: March 2008 |
Owner: Grand
Manor Property LLC
Operator: Grand Manor Nursing & Rehabilitation Center, LLC Registered Agent: Mark Rubin |
Legal Action: Uncorrected Class II Notice of Noncompliance |
| Description: The facility failed to assess, monitor, and document a resident’s condition and promptly report laboratory results indicative of a urinary tract infection; administer long-acting insulin as prescribed; obtain physician orders for sliding scale insulin; obtain and record accuchecks as ordered and administer sliding scale insulin as prescribed; and notify the physician of abnormal accucheck readings. | ||
| Facility:
Cape Albeon
Valley Park, MO 100-Bed Assisted Living Facility Date of Notice: March 2008 |
Owner: The Good
Samaritan Independent Living, Inc.
Operator: Same Registered Agent: Charlotte Lehmann |
Legal Action: Uncorrected Class II Notice of Noncompliance |
| Description: The facility failed to develop a safe and effective system of medication administration for one of three sampled residents with an order to self-administer medication and for two of three sampled residents without an order to self-administer medication. The facility failed to follow physician’s orders for one of three sampled residents and to have physician’s orders for over the counter medications for two of three sampled residents. | ||
| Facility:
Autumn View Gardens at Schuetz Rd.
St. Louis, MO 100-Bed Assisted Living Facility Date of Notice: March 2008 |
Owner: Bethesda
Foundation
Operator: Same Registered Agent: C T Corporation System |
Legal Action:
Class I Notice of Noncompliance In a letter from DHSS: On 3/31/2008, SLCR staff completed a revisit at the facility and determined that the Class I deficiency could be lowered to a Class II.
|
| Description: The facility failed to meet the needs of two residents who had repeated elopements from the facility. After each resident’s elopement, the facility failed to provide adequate supervision to prevent the residents from eloping again and failed to assess the residents to determine if the facility could meet their needs any longer. The facility failed to provide protective oversight for two confused residents with a history of multiple elopements. The facility failed to ensure the residents did not leave the facility unsupervised. One resident walked out the first floor exit door and was found on the road in front of the facility by a passerby on 3/5/08 at 12:10 a.m. Review of the National Weather Service’s website, showed on 3/4/08 at 11:51 p.m. the temperature was 23.0 degrees F and there was approximately 11-12 inches of snow on the ground in this area. The other resident left the facility on 9/4/07 at approximately 5:25 a.m. A passer-by came to the facility office to report a person on the ground across the street on the church parking lot. The resident had a bump on the back of his/her head that was red. Resident complained of a headache and was crying. The facility failed to maintain adequate staff in the facility on the night shift for 47 of 57 night shifts reviewed. The facility failed to have sufficient staff to monitor and provide care to meet the needs of the residents (Resident #11, #10, #8, #13, #14 and #12). The facility also failed to have sufficient staff on duty during the night shift to meet the staffing requirements for fire safety. These failures had the potential to affect all residents in the facility. | ||
| Facility:
Parkview Residential Care
Crystal City, MO 52-Bed Residential Care Facility Date of Notice: March 2008 |
Owner:
Jean-Baptist, Phillipe & Debra Hahn
Operator: DMP Enterprises, Inc. Registered Agent: Mark C. Goldenburg |
Legal Action: Uncorrected Class II Notice of Noncompliance |
| Description: The facility failed to ensure two of six emergency lights were operable. The facility failed to maintain the temperature above 68 degrees Fahrenheit (F) for six of twelve resident rooms and two hallways on the first floor. | ||
| Facility:
The Cedars at the JCA
Chesterfield, MO 230-Bed Skilled Nursing Facility Date of Notice: March 2008 |
Owner: Not
Listed
Operator: Jewish Center for Aged Registered Agent: Not Listed |
Legal Action: Uncorrected Class II Notice of Noncompliance |
| Description: The facility failed to follow their own policy and acceptable practice in the administration of cardio-pulmonary resuscitation (CPR) for one resident who was unresponsive. Staff initiated CPR on a mattress instead of a hard surface as instructed during CPR certification. Also, two of the staff that participated in the CPR attempt were not currently certified in CPR administration. | ||
| Facility:
Arbor Place of Festus, Inc.
Festus, MO 81-Bed Skilled Nursing Facility Date of Notice: May 2008 |
Owner: Arbor
Health Properties, Inc.
Operator: Arbor Place of Festus, Inc. Registered Agent: John M. Sells |
Legal Action:
Class I Notice of Noncompliance In a letter from DHSS: On 5/20/2008, SLCR staff completed a revisit at the facility and determined that the Class I deficiency could be lowered to a Class II.
|
| Description: The facility failed to provide protective oversight and supervision for one resident identified as an elopement risk (Resident #14) who resided on a secured unit. The resident eloped from the secured unit through an alarmed window. The staff did not know the resident was gone for at least two hours, when the resident telephoned the facility and told staff to check his/her bed. The facility was aware that the resident had a long history of elopements from prior facilities. The resident frequently told staff he/she was going to leave. The police found the resident in Kansas City. The facility also failed to provide protective oversight and supervision for one resident who sustained skin tears and was improperly transferred (Resident #11). | ||
| Facility:
Autumn View Gardens at Schuetz Rd.
St. Louis, MO 100-Bed Assisted Living Facility Date of Notice: June 2008 |
Owner: Bethesda
Foundation
Operator: Same Registered Agent – CT Corporation System |
Legal Action: Uncorrected Class II Notice of Noncompliance |
| Description: The facility failed to follow physician’s orders for two residents. | ||
| Facility:
Union Manor RCF
St. Louis, MO 52-Bed Residential Care Facility Date of Notice: June 2008 |
Owner: Alma
Cook
Operator: Same Registered Agent: Not Listed |
Legal Action: Uncorrected Class II Notice of Noncompliance |
| Description: The facility failed to ensure one of six sampled residents was able to negotiate a path to safety within five minutes and without verbal or physical assistance from staff. The facility failed to provide three substantial meals per day for two of seven days of the week, Saturdays and Sundays. | ||
| Facility:
Friendship Village of West County
Chesterfield, MO 99-Bed Skilled Nursing Facility Date of Notice: July 2008 |
Owner:
Friendship Village of West County
Operator: Same Registered Agent: Tim Cain |
Legal Action:
Class I Notice of Noncompliance In a letter from DHSS: On 7/22/2008, SLCR staff completed a revisit at the facility and determined that the Class I deficiency could be lowered to a Class II.
|
| Description: Facility staff failed to complete ongoing assessments, develop, revise and implement interventions to prevent falls and failed to notify the physician in a timely manner for one resident (Resident #17) with multiple falls and injuries. In two months, Resident #17 fell 9 times and received multiple injuries including a brain injury and two separate fractures of the pelvis, all requiring hospitalization. When readmitted, staff did not implement measures to prevent further falls. Additionally, facility staff failed to develop a care plan with individualized approaches and interventions for falls, based on the facility’s comprehensive assessment for five residents (Resident #4, #5, #12, #19 & #18) to prevent future falls. | ||
| Facility:
Heritage Care Center
St. Louis, MO 120-Bed Skilled Nursing Facility Date of Notice: July 2008 |
Owner: Heritage
Park Assoc. LP
Operator: Heritage Care Center of Berkeley LLC Registered Agent: Robert Craddick |
Legal Action: Uncorrected Class II Notice of Noncompliance |
| Description: The facility failed to provide services that met professional standards for quality care for three of thirteen sampled residents by failure to provide a prescribed medication in accordance with physician’s orders, and to flush a feeding tube with water prior to and after administering medications for one resident; failed to obtain prescribed laboratory work for one resident; and failed to inform a resident’s physician of laboratory results. The facility failed to assess a medical emergency in a timely manner for one resident. | ||
| Facility:
Green Valley Nursing & Rehab Center
St. Louis, MO 150-Bed Skilled Nursing Facility Date of Notice: August 2008 |
Owner: Green
Valley Real Property LLC
Operator: Green Valley Nursing & Rehab Center, LLC Registered Agent: Kimberly Kusack |
Legal Action: Uncorrected Class II Notice of Noncompliance |
| Description: The facility failed to monitor, assess, and provide interventions for a resident with extensive bruising to the right lower extremity of one resident (Resident #30). An x-ray of the right lower extremity, eight days after staff noted the bruise, confirmed a femur fracture. | ||
| Facility: St.
Sophia Health & Rehab Center
Florissant, MO 240-Bed Skilled Nursing Facility Date of Notice: September 2008 |
Owner: Ladelle Investment
Company, Inc.
Operator: Same Registered Agent: Dennis G. Menos |
Legal Action: Uncorrected Class II Notice of Noncompliance |
| Description: The facility staff failed to provide care in a manner to prevent accidental injury for eight residents. | ||
| Facility: Oak
Park Nursing Center
St. Louis, MO 120-Bed Skilled Nursing Facility Date of Notice: September 2008 |
Owner: Oak Park Real Estate
LLC
Operator: Berthold Nursing Center Registered Agent: Clifton L. Shirrell |
Legal Action: Class I Notice of Noncompliance |
| Description: The facility failed to provide care and oversight in a manner to prevent an accidental injury for one resident identified at risk for accidental injury. | ||
| Facility: Saddler
Residential Care Facility
St. Louis, MO 22-Bed Assisted Living Facility Date of Notice: October 2008 |
Owner: Saddler,
LaTerryl
Operator: Saddler Residential Care Facility, Inc. Registered Agent: Terry Saddler |
Legal Action: Class I Notice of Noncompliance |
| Description: Based on interview and record review, the facility failed to meet the needs, assess and treat one of four sampled residents (Resident #1), who showed a decline in his/her medical condition, developed multiple pressure ulcers and became dehydrated and unresponsive. The facility failed to ensure the resident’s pressure sores were treated appropriately and treated daily by a licensed nurse. The facility failed to notify the resident’s physician of the resident’s accurate medical and physical condition. The resident was admitted to the hospital with extensive contractures of his/her extremities in flexion at the wrists, elbows, shoulders, hips and knees, and multiple pressure ulcers with at least six ulcers situated over the lower torso and lower extremities. The census was 19. Based on interview and record review, the facility failed to provide qualified staff to meet the care needs for a resident who showed a decline in his/her medical condition and developed multiple pressure ulcers. The unqualified staff provided pressure ulcer treatments and dressing changes to some of the resident’s pressure ulcers. The resident acquired the pressure ulcers in the facility, they increased in size and became gangrenous (dead tissue) (Resident #1). The census was 19. | ||
| Facility: Tesson
Heights
St. Louis, MO 72-Bed Residential Care Facility Date of Notice: October 2008 |
Owner: HCP Tesson,
LLC
Operator: CSL Leaseco, Inc. Registered Agent: C.T. Corporation System |
Legal Action: Uncorrected Class II Notice of Noncompliance |
| Description: The facility failed to ensure one of five sampled residents was able to negotiate a path to safety. The facility failed to place residents in the facility according to their abilities. The facility placed residents who required the use of a walker for ambulation, on a floor which did not have direct exits at grade, a ramp, or no more than two steps to grade with a handrail. Seven of seven sampled residents, who resided on the second floor, required a walker for ambulation and had two flights of stairs to exit the building in an emergency. | ||
| Facility: Loving
Care Home
St. Louis, MO 109-Bed Assisted Living Facility Date of Notice: October 2008 |
Owner: Jamieson Realty,
LLC
Operator: Lindenwood Care Corporation Registered Agent: Mark Hendin |
Legal Action: Uncorrected Class II Notice of Noncompliance |
| Description: The facility failed to intervene when a resident exhibited verbal and physical aggression towards another resident. The facility failed to ensure residents were safe from verbal aggression or physical altercations from other residents and failed to implement measures to prevent incidents from occurring. The facility failed to develop a safe and effective system of medication administration. | ||
| Facility:
Blanchette Place Care Center
St. Charles, MO 180-Bed Skilled Nursing Facility Date of Notice: October 2008 |
Owner: CRAVIV, LLC
Operator: Cathedral Rock of St. Charles, Inc. Registered Agent: Anthony J. Soukenik |
Legal Action: Class I Notice of Noncompliance |
| Description: The facility failed to provide respiratory treatments as ordered, failed to adequately monitor and assess changes in respiratory symptoms, and notify the resident’s physician of the changes for one resident with a tracheostomy. On 9/24/08, the resident who had a full code status was found without a pulse or respirations. Staff failed to institute cardiopulmonary resuscitation (CPR) or call 911 (emergency service). The resident died. | ||
| Facility: Oak
Park Nursing Center
St. Louis, MO 120-Bed Skilled Nursing Facility Date of Notice: December 2008 |
Owner: Oak Park Real Estate
LLC
Operator: Berthold Nursing Center Registered Agent: Clifton L. Shirrell |
Legal Action: Uncorrected Class II Notice of Noncompliance |
| Description: The facility failed to provide care and oversight in a manner to prevent an accidental injury for one resident identified at risk for accidental injury. | ||
| Facility: Page
Manor
St. Louis, MO 49-Bed Assisted Living Facility Date of Notice: December 2008 |
Owner: Malik, Saleh
M.
Operator: Malik Home, LLC Registered Agent: Saleh Malik |
Legal Action: Uncorrected Class II Notice of Noncompliance |
| Description: The facility failed to provide smoke separation between floors by not ensuring smoke doors closed and latched properly for one of two smoke doors leading to the basement/annex. The facility failed to ensure residents did not smoke in sleeping quarters, while not directly supervised, for eight of eight sampled residents who smoked in their rooms or witnessed smoking in resident rooms and in the furnace room. The facility failed to provide clean mattresses and maintain mattresses in good repair for five of nine sampled resident rooms. The administrator failed to spend sufficient time and attention to the management of the facility necessary to ensure the well-being, safety and best interests of the residents. The facility failed to complete annual community based assessments (CBA) and semi-annual CBAs for one of three sampled residents and complete a CBA within five days of admission for three expanded residents. | ||
| Faciltiy: Chateau
Ann Marie
St. Louis, MO 20-Bed Residential Care Facility Date of Notice: December 2008 |
Owner: Henlon, Warren
L.
Operator: Chateau Ann Marie, LLC Registered Agent: Karen Reiter |
Legal Action: Uncorrected Class II Notice of Noncompliance |
| Description: The facility failed to screen a resident and employees for tuberculosis. The facility failed to follow physician’s orders for four residents. The facility failed to ensure the same staff person who prepared medications, also administered the medications to the residents. The facility also failed to ensure staff was properly certified in medication administration. The facility failed to properly seal, label, date and monitor food expiration dates to ensure foods are not kept beyond the recommended expiration date. | ||