| 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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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.
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| 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.
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| 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.
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| 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.
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| 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.
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| 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. | ||