| Return to MCQC Nursing Home Non-Compliance Page | 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. | ||