ST. LOUIS REGION

Facility: Northgate Park Nursing Home

Florissant, MO

158-Bed Skilled Nursing Facility

Date of Notice: January 2009

Owner: LaSalle Real Estate Assets LLC

Operator: FLO-GP Leasing Co., LLC

Registered Agent: Mayer S. Klein

Legal Action: Class I Notice of Noncompliance

In a letter from DHSS: On 1/16/2009, 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 adequately supervise one resident, which resulted in the resident’s death. Facility staff did not observe the resident for over four hours and did not conduct routine rounds on the resident during two shifts. Staff found the resident during the night shift, outdoors on a patio in cold, wet weather. The resident died with hypothermia.  

Facility: Chateau Ann Marie

St. Louis, MO

20-Bed Residential Care Facility

Date of Notice: January 2009

Owner: Henlon, Warren L.

Operator: Chateau Ann Marie, LLC

Registered Agent: Karen Michelle Reiter

Legal Action: Uncorrected Class II Notice of Noncompliance

Description: The facility failed to insure that the exit signs were illuminated by both normal and emergency lighting. The facility failed to maintain documentation and certification that the fire alarm system was tested and inspected annually by an approved qualified service representative. The facility failed to insure that the doors between floors that had self closing devices remain closed. The facility failed to insure that the battery back up system for the emergency light was operational. The facility failed to enforce the regulation that only one appliance can be connected to one extension cord and only two appliances may be served by one duplex receptacle.

Facility: Arbor Place of Festus, Inc.

Festus, MO

81-Bed Skilled Nursing Facility

Date of Notice: January 2009

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 1/05/2009, 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 supervision to protect residents from abuse, accidents, and injury. Out of 24 sampled residents, the facility failed to protect a resident from sexual abuse, provide supervision and interventions to prevent a fall for one resident, reduce the risk of incidence of resident to resident confrontation for four residents, reduce the risk of incidence of resident to resident physical abuse for two residents, prevent access of non-prescribed medications for two residents, and prevent the incidence of ingestion of non-food substances for one resident.

Facility: Arbor Place of Festus

Festus, MO

81-Bed Skilled Nursing Facility

Date of Notice: February 2009

Owner: Arbor Health Properties, Inc.

Operator: Arbor Place of Festus, Inc.

Registered Agent: John M. Sells

Legal Action: Uncorrected Class II Notice of Noncompliance

Description: The facility staff failed to maintain resident rooms at comfortable room temperatures for the residents. The facility failed to update appropriate interventions after one resident hit two other residents. The facility failed to serve food that was palatable with cold foods at or below 41 degrees Fahrenheit (F) and hot foods at 140 degrees (F) or above for two of two observed meals.

Facility: Ava Place

St. Louis, MO

40-Bed Residential Care Facility

Date of Notice: February 2009

Owner: Deaconess Long Term Care

Operator: Same

Registered Agent: C T Corporation

Legal Action: Class II Notice of Noncompliance

Description: Based on observation and interview, the facility failed to ensure that the complete fire alarm system was in accordance with the National Fire Protection Association (NFPA) 72. The census was 25.

Facility: Cedars at the JCA

Chesterfield, MO

230-Bed Skilled Nursing Facility

Date of Notice: February 2009

Owner: Jewish Center for Aged

Operator: Same

Registered Agent: Not Listed

Legal action: Uncorrected Class II Notice of Noncompliance

Description: The facility failed to administer medications per physician’s orders. Ten of eleven sampled residents had missing doses of medications or missing treatments. The facility failed to appropriately monitor and assess one of eleven sampled residents after a fall and failed to monitor and assess one of eleven sampled residents for pain.

Facility: Superior Residential Care

St. Louis, MO

30-Bed Residential Care Facility

Date of Notice: February 2009

Owner: Klotz Real Estate LLC

Operator: Superior Residential Care, LLC

Registered Agent: Kenneth Klotz

Legal Action: Uncorrected Class II Notice of Noncompliance

Description: The Administrator failed to devote sufficient time and attention to the management of the facility as is necessary for the health, safety, and welfare of the residents. The facility failed to develop a safe and effective system of medication administration, for three of ten expanded residents who administered inhalers improperly; and for four of ten expanded residents who did not receive medications as ordered by the physician.

Facility: Saddler Residential Care Facility

St. Louis, MO

22-Bed Assisted Living Facility

Date of Notice: February 2009

Owner: Saddler, LaTerryl

Operator: Saddler Residential Care Facility, Inc.

Registered Agent: LaTerryl Saddler-Chavis

Legal Action: Uncorrected Class II Notice of Noncompliance

Description: The facility failed to supply curtains and drapes treated to be flame-resistant.

Facility: Creve Coeur Manor

St. Louis, MO

149-Bed Skilled Nursing Facility

Date of Notice: February 2009

Owner: Creve Coeur Place, LLC

Operator: Creve Coeur Manor, LLC

Registered Agent: Sharo Shirshekan

Legal Action: Class I Notice of Noncompliance

Description: The facility staff failed to maintain exit doors to be free from obstructions such as snow and ice. These impediments prevented full and instant use of the exit doors affecting all occupants of the facility in the event of an emergency requiring an evacuation. The resident census was 52. (Note: At the time of the exit conference on 1/29/09, the removal of the snow accumulations allowing the exit doors to readily open and use of cleared pathways, abated the imminent danger. The facility had not completed inservice education for all maintenance staff to ensure the designated exits remained unobstructed. The deficiency was lowered to a Class II. This statement does not denote that the facility has complied with Sectiom 198.026.1 RSMo regarding prompt remedial action for a violation of a Class I standard.

Facility: Newstead Place

St. Louis, MO

20-Bed Residential Care Facility

Date of Notice: February 2009

Owner: Center Housing II Inc.

Operator: Independence Center

Registered Agent: C T Corporation

Legal Action: Uncorrected Class II Notice of Noncompliance

Description: The facility failed to ensure that a visual or a tactile alarm was installed for a hearing impaired occupant.

Facility: Chateau Ann Marie

St. Louis, MO

20-Bed Residential Care Facility

Date of Notice: February 2009

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 residents and staff for tuberculosis. The deficiency was originally cited on 09/10/2008 and found to be uncorrected on 12/01/2008 and 01/30/2009.

Facility: St. Johns Place

St. Louis, MO

94-Bed Skilled Nursing Facility

Date of Notice: March 2009

Owner: Bentley Development Corp.

Operator: St. John’s Place, Inc.

Registered Agent: Jerome Kraus

Legal Action: Class I Notice of Noncompliance

Description: The facility failed to follow the resident’s health care directive and the physician’s directive to provide cardiopulmonary resuscitation (CPR) for one resident (Resident #1) of three sampled residents, failed to have a policy compatible with providing CPR whenever needed, and failed to have CPR certified staff in the facility at all times. This potentially could affect the forty-four full code status residents in the facility. Resident #1 was found unresponsive and was a full code and staff did not provide CPR. Resident #1 died.

Facility: Sabbath Manor

St. Louis, MO

64-Bed Residential Care Facility

Date of Notice: March 2009

Owner: SADAF, LLC

Operator: Frasat, LLC

Registerd Agent: Bilkiss Cahudhry

Legal Action: Uncorrected Class II Notice of Noncompliance

Description: The facility failed to ensure staff administered medication according to the physician’s order for one resident. The facility failed to ensure a criminal background check (CBC) and a check of the employee disqualification list (EDL) was completed prior to allowing staff to have contact with residents for two of two sampled employees.

Facility: Desmet Retirement Community

Florissant, MO

90-Bed Residential Care Facility

Date of Notice: April 2009

Owner: Desmet RHF Housing, Inc.

Operator: Same

Registered Agent: National Registered Agents, Inc.

Legal Action: Class I Notice of Noncompliance

In a letter from DHSS: On 04/29/2009, 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 properly identify and assess a resident who required a higher level of care due to severe occurrence of diarrhea and a weakened condition. The resident was readmitted to the facility from skilled nursing and continued to have diarrhea. Staff did not notify the resident’s physician of the resident’s change in condition. The resident was sent to the hospital after staff found the resident with blue colored extremities and had an oxygen saturation level at 66% (normal range 95% to 100%). The resident expired in the hospital the next day. The facility failed to meet the needs for three sampled residents with diarrhea and falls. One resident who experienced diarrhea for several days and a weakened condition was sent to the hospital and expired. In addition, the facility failed to follow physician’s orders for two additional sampled residents.

Facility: Life Care Center of St. Louis

St. Louis, MO

100-Bed Skilled Nursing Facility

Date of Notice: April 2009

Owner: Not Listed

Operator: C.M.C. Extended Care Center, Inc.

Registered Agent: CT Corporation System

Legal Action: Uncorrected Class II Notice of Noncompliance

Description: The facility staff failed to assess for the presence of pain and provide effective pain management for three residents. The facility failed to provide necessary treatment to promote healing, including clean wound care technique and adequate pain management for one resident.

Facility: Arbor Place of Festus

Festus, MO

81-Bed Skilled Nursing Facility

Date of Notice: April 2009

Owner: Arbor Health Properties, Inc.

Operator: Arbor Place of Festus, Inc.

Registered Agent: John Sells

Legal Action: Class I Notice of Noncompliance

Description: The facility failed to provide prompt intervention and adequate assessment for two residents with a change in condition following head injuries. One resident was hospitalized with a subdural hematoma and multiple facial fractures and the other resident had a hematoma and a facial abrasion.

Facility: Crestwood Health Care Center, LLC

Florissant, MO

Date of Notice: April 2009

Owner: Florissant Property, LLC

Operator: Crestwood Health Care Center, LLC

Registered Agent: Robert Craddick

Legal Action: Uncorrected Class II Notice of Noncompliance

Description: The facility failed to prevent the commingling of resident funds with facility operating funds for 54 residents identified on the facility’s Interim Aged Analysis Report. The facility failed to maintain written authorizations for residents’ expenditures. This affected three of five sampled residents (Residents #33, #53 and #77).

Facility: Cori Manor Healthcare & Rehab Center

Fenton, MO

124-Bed Skilled Nursing Facility

Date of Notice: April 2009

Owner: Cori Manor Properties, LLC

Operator: Cori Manor Healthcare & Rehab Center, LLC

Registered Agent: Mark Rubin

Legal Action: Class I Notice of Noncompliance

Description: The facility failed to ensure hot water temperatures in resident accessible areas did not exceed 120 degrees Fahrenheit. This condition affected two of 21 residents reviewed and three residents outside the sample.

Facility: Lutheran Senior Services at Richmond Terrace

St. Louis, MO

99-Bed Residential Care Facility

Date of Notice: May 2009

Owner: Lutheran Senior Services

Operator: Same

Registered Agent: Not Listed

Legal Action: Uncorrected Class II Notice of Noncompliance

Description: The facility failed to maintain the fire alarm in accordance with NFPA 72. The facility failed to maintain the sprinkler system in accordance with NFPA 13.

Facility: Mark Twain Manor

Bridgeton, MO

120-Bed Skilled Nursing Facility

Date of Notice: May 2009

Owner: MTH Associates Limited Partnership

Operator: N & R of Poplar Bluff, Inc.

Registered Agent: Charlotte Stutts

Legal Action: Uncorrected Class II Notice of Noncompliance

Description: The facility failed to ensure staff provided services to promote the healing of pressure sores and to prevent the development of new pressure sores for one of 13 sampled residents by the failure to periodically reposition the resident and the failure to place the resident on a pressure relief device when seated in the chair. The facility failed to ensure staff provided residents adequate assistance devices and supervision during transfers between surfaces to prevent accidental injuries for four of 13 sampled residents.

Facility: Whispering Oaks

Wildwood, MO

70-Bed Residential Care Facility

Date of Notice: May 2009

Owner: Whispering Oaks Residential Care Facility LLC

Operator: Whispering Oaks RCF Management Company, Inc.

Registered Agent: Naren Chaganti

Legal Action: Uncorrected Class II Notice of Noncompliance

Description: The facility failed to ensure an electrical inspection was completed every two years. The facility failed to provide a licensed Administrator who was responsible for the management and operations of the facility. The Owner/Administrator failed to ensure the facility followed all rules and regulations by failure to provide an administrator, ensure inspections were completed, the well drinking water was tested, and to ensure residents were provided with oversight and appropriate care. The facility failed to have sufficient staff on duty during the day and evening shifts to meet the staffing requirements for fire safety for four of ten day shifts reviewed and six of ten evening shifts reviewed. The facility failed to follow physician’s orders for four of five sampled residents who did not receive intramuscular injections as ordered. The facility failed to request a criminal background check (CBC) prior to hire, for two of three sampled employees and for one of two expanded sampled employees.

Facility: Hopewell Group Home

St. Louis, MO

12-Bed Residential Care Facility

Date of Notice: May 2009

Owner: Holmes Annquienette D.

Operator: Hopewell Center

Registered Agent: Not Listed

Legal Action: Class II Notice of Noncompliance

Description: The facility failed to maintain the fire alarm in accordance with NFPA 101.

Facility: Green Valley Nursing & Rehab

St. Louis, MO 63138

150-Bed Skilled Nursing Facility

Date of Notice: May 2009

Owner: Green Valley Real Property LLC

Operator: Green Valley Nursing & Rehab Center LLC

Registered Agent: Moshe Orlinsky

Legal Action: Class I Notice of Noncompliance

In a letter from DHSS: On 05/13/2009, 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 document one of five sampled residents’ condition following an emergency room evaluation and failed to administer routine medications as ordered. The resident’s condition deteriorated and staff found the resident slumped over the toilet. Staff returned the resident to his/her room, did not assess him/her, and staff failed to follow the physician’s order to send the resident to the hospital. The resident expired (Resident #1). The facility also failed to monitor and document on one of six expanded sampled residents after the resident had an acute change in condition (Resident #2).

Facility: Life Care Center of St. Louis

St. Louis, MO

100-Bed Skilled Nursing Facility

Date of Notice: May 2009

Owner: HCRI Missouri Properties LLC

Operator: C.M.C. Extended Care Center, Inc.

Registered Agent: CT Corporation System

Legal Action: Uncorrected Class II Notice of Noncompliance

Description: The facility failed to follow physician’s orders for six of nine sampled residents and failed to follow acceptable standards of practice for the administration of medications. The facility failed to ensure staff provided two residents, who were unable to do their own activities of daily living (ADL’s), the necessary care and services to maintain good personal hygiene and prevent body odor. The facility failed to provide the appropriate treatment and services to minimize the potential for complications from tube feeding (TF) for four residents. The facility failed to implement a safe and effective system of medication administration, resulting in a 7.54% medication error rate. The facility failed to provide acceptable infection control practices and failed to provide a safe and sanitary environment to prevent the transmission of infection for one resident. The facility failed to ensure that nursing staff washed their hands after each direct resident contact and when indicated by professional practices during personal care for five residents.

Facility: Desmet Retirement Community

Florissant, MO

90-Bed Residential Care Facility

Date of Notice: May 2009

Owner: Desmet RHF Housing, Inc.

Operator: Desmet RHF Housing, Inc.

Registered Agent: National Registered Agents, Inc.

Legal Action: Uncorrected Class I Notice of Noncompliance

In a letter from DHSS: On 04/29/2009, 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 for two of two sampled residents. One resident, who experienced a fall and left side weakness, was sent to the hospital and diagnosed with a cerebrovascular accident. One resident’s laboratory results were not reported to the physician. The resident became weak, could not stand, had slurred speech, and was sent to the hospital. The resident was diagnosed with a urinary tract infection, possible septicemia, and dehydration.

Facility: Brook View Nursing Home, Inc.

Maryland Heights, MO

201-Bed Skilled Nursing Facility

Date of Notice: June 2009

Owner: Lierman Family Partnership LLP

Operator: Brook View Nursing Home, Inc.

Registered Agent: Mark Liermann

Legal Action: Uncorrected Class II Notice of Noncompliance

Description: An annual survey and abbreviated survey was completed on 03/31/2009. The facility was not in compliance with participation requirements. A revisit was completed on 05/21/2009. The facility failed to make correction to the following violations: Assess and analyze medical symptoms prior to using restraints, to determine the appropriateness and least restrictive interventions. Update five residents’ care plans to reflect the residents current needs; Ensure nursing staff adequately document the resident’s ongoing condition in the resident’s nurses’ notes, monitor consumption records to ensure facility staff were documenting meal consumption, failed to monitor nutritional deficits, and failed to ensure the resident received adequate liquids for one resident diagnosed with malnutrition; To complete an updated pain assessment and failed to develop interventions and approaches to address the resident’s pain; Ensure residents received the necessary care and services to promote healing and prevent new sores from developing; Ensure one resident’s indwelling urinary catheter drainage bag and tubing remained off the floor, which presented a risk for urinary tract infection, and failed to monitor and provide services to prevent the recurrence of a urinary tract infection; Ensure one resident who the facility identified at high risk for falls received adequate oversight and supervision to prevent accidents when staff placed the resident in a geri-rocker with tray and the resident fell out and pulled the television out of the cabinet; To implement a system to maintain proper temperatures for one of two medication refrigerators, used to store insulin and other medications that required refrigeration; facility staff failed to ensure they removed soiled gloves and washed hands as necessary during personal care for six residents.

Facility: Oasis Residential Care – West

St. Louis, MO

20-Bed Residential Care Facility

Date of Notice: June 2009

Owner: King, Nettie

Operator: Oasis Residential Care, Inc.

Registered Agent: Sherman Strong

Legal Action: Uncorrected Class II Notice of Noncompliance

Description: The facility failed to follow physician’s orders for one resident who did not receive intramuscular injections, blood pressure medication, and blood pressure checks. The facility also failed to follow physician’s orders for one resident who refused his/her treatment medications.

Facility: Mary, Queen and Mother Center

Shrewsbury, MO

230-Bed Skilled Nursing Facility

Date of Notice: June 2009

Owner: Mary, Queen and Mother Assn.

Operator: Mary, Queen and Mother

Registered Agent: Karen Ledbetter

Legal Action: Class I Notice of Noncompliance

Description: Based on interview and record review, the facility failed to provide timely and ongoing monitoring and assessment for one of three sampled residents (Resident #50). The resident’s condition deteriorated and staff failed to report findings to the resident’s physician in a timely manner, and failed to follow the resident’s directive and the physician’s order to provide Cardiopulmonary Resuscitation (CPR) when staff discovered the resident was without signs of life. The resident expired. The census was 203 residents.

Facility: Union Manor Residential Care Facility

St. Louis, MO

52-Bed Residential Care Facility

Date of Notice: July 2009

Owner: Alma Cook

Operator: Same

Registered Agent: N/A

Legal Action: Class I Notice of Noncompliance

Description: The facility failed to act in a manner to protect residents from physical abuse, which adversely affected the resident (Resident #2). Residents #5, #8, #3, #7, and #4 verified that the abuse occurred to Resident #2 in the facility. The facility failed to ensure one resident (Resident #2) who was unable to speak, disoriented to time and place, and agitated at times, was free from physical and verbal abuse by facility staff.

Facility: Whispering Oaks

Wildwood, MO

70-Bed Residential Care Facility

Date of Notice: July 2009

Owner: Cox Real Estate Corporation

Operator: Whispering Oaks RCF

Registered Agent: Naren Chaganti

Legal Action: Class I Notice of Noncompliance

Description: The facility failed to ensure room temperatures did not exceed eight-five degrees (85) Fahrenheit (F), and failed to ensure resident’s comfort needs were met by allowing a heat index of 99 degrees Fahrenheit.

Facility: Bellefontaine Gardens Nursing & Rehab.

St. Louis, MO

96-Bed Skilled Nursing Facility

Date of Notice: July 2009

Owner: Not Listed

Operator: Bellefontaine Gardens Nursing & Rehab, Inc.

Registered Agent: James Lincoln

Legal Action: Uncorrected Class II Notice of Noncompliance

Description: The facility failed to effectively assess, supervise, and intervene to prevent the elopement of one resident.

Facility: Northgate Park Nursing Home

Florissant, MO

158-Bed Skilled Nursing Facility

Date of Notice: July 2009

Owner: LaSalle Real Estate Assets, LLC

Operator: FLO-GP Leasing Co., LLC

Registered Agent: Mayer Klein

Legal Action: Class I Notice of Noncompliance

Description: The facility failed to provide oversight and supervision for one of three sampled residents who staff assessed as an elopement risk and who had a history of elopement. The resident left the facility without staff knowledge. Staff did not check for missing residents when a door alarm sounded per the facility’s policy and procedure.

Facility: Marymount Manor

Eureka, MO

174-Bed Skilled Nursing Facility

Date of Notice: July 2009

Owner: City of Eureka

Operator: Marymount Manor, LLC

Registered Agent: Greg Spence

Legal Action: Uncorrected Class II Notice of Noncompliance

Description: At the revisit on 07/20/09 the facility was found to have the following uncorrected violations. The facility census was 118 residents. The facility staff failed to properly assess/evaluate the use of a restraint, obtain appropriate physician orders, care plan its use, and obtain informed consent before utilizing a restraint for one resident. Facility staff failed to review and revise a plan of care for falls for one resident with a history of falls. The facility staff failed to evaluate and analyze hazards and risks for falls, implement interventions to reduce the risks, and monitor and modify the interventions when necessary for two residents. The facility staff failed to remove soiled gloves and properly wash hands as needed when incontinent care was provided for five residents.

Facility: Union Manor Residential Care Facility

St. Louis, MO

52-Bed Residential Care Facility

Date of Notice: July 2009

Owner: Alma Cook

Operator: Same

Registered Agent: N/A

Legal Action: Uncorrected Class I & II Notice of Noncompliance

Description: The facility failed to act in a manner to protect residents from physical abuse, which adversely affected the resident (Resident #2). Residents #5, #8, #3, #7, and #4 verified that the abuse occurred to Resident #2 in the facility. During the revisit on 7/16/09, the perpetrator of the abuse continued to work and had contact with residents after the allegation of abuse was made. The facility failed to ensure one resident (Resident #2) who was unable to speak, disoriented to time and place, and agitated at times, was free from physical and verbal abuse by facility staff. During the revisit on 7/16/09, the perpetrator of the abuse continued to work and had contact with residents after the allegation of abuse was made. The facility failed to maintain a separation between floors by ensuring one of one door providing separation, in building one, between the first floor and the basement, was closed. The facility failed to ensure two of two sampled residents and one expanded sampled resident were able to negotiate a path to safety. The facility failed to provide three substantial meals per day for two of seven days of the week, Saturdays and Sundays.

Facility: Allways Kare Residential Facility

St. Louis, MO

20-Bed Residential Care Facility

Date of Notice: July 2009

Owner: Allways Kare Residential Facility

Operator: Same

Registered Agent: Not Listed

Legal Action: Uncorrected Class II Notice of Noncompliance

Description: The facility failed to have two unobstructed exits remote from each other. The facility failed to have inspections and written certifications of the complete fire alarm system in accordance with NFPA 72, 1999.

Facility: North Valley Nursing & Rehab. Center

St. Louis, MO

94-Bed Skilled Nursing Facility

Date of Notice: August 2009

Owner: North Valley Real Property LLC

Operator: Same

Registered Agent: Kimberly Kusack

Legal Action: Class I Notice of Noncompliance

Description: The facility failed to provide protective oversight and/or follow the facility’s policies on suicidal ideation, resident to resident altercations, daily room checks, and searches to prevent harm for six of nine sampled residents and provide a safe environment for other residents. The facility failed to adequately monitor one of nine sampled residents to prevent an elopement.

Facility: Tesson Heights

St. Louis, MO

72-Bed Residential Care Facility

Date of Notice: September 2009

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.

Facility: Sabbath Manor

St. Louis, MO

64-Bed Residential Care Facility

Date of Notice: September 2009

Owner: Sadaf, LLC

Operator: Frasat, LLC

Registered Agent: Bilkiss Cahudhry

Legal Action: Uncorrected Class II Notice of Noncompliance

Description: At the revisit on 09/03/2009, the facility still failed to ensure one of two required exits on the second floor was free of obstructions. During the onsite inspection, the door of the required exit in one resident room was obstructed by a resident bed and a bag of clothes.

Facility: Whispering Oaks

Wildwood, MO

70-Bed Residential Care Facility

Date of Notice: September 2009

Owner:  Cox Real Estate Corp.

Operator: Whispering Oaks RCF Management Company, Inc.

Registered Agent: Naren Chaganti

Legal Action: Class I Notice of Noncompliance

Description: The facility failed to provide protective oversight for a resident who climbed up onto the facility’s roof, while it was misting rain, to repair the facility’s guttering. The resident fell from the wet ladder approximately 15 feet to the flat roof below and sustained a deep laceration requiring 11 stitches. In addition, the facility failed to provide oversight for two sampled residents who work at the facility because there are no activities.

Facility: Avalon Garden

St. Louis, MO

77-Bed Skilled Nursing Facility

Date of Notice: October 2009

Owner: BRNCIC Inc.

Operator: JPAM Management & Consulting, Inc.

Registered Agent: John Brencick

Legal Action: Uncorrected Class II Notice of Noncompliance

Description: The facility failed to provide care that met professional standards of quality for four of nine sampled residents. The facility failed to apply pressure relieving boots 24 hours a day and follow a physician’s order to obtain a timely podiatry consult for one resident with a recurring pressure ulcer on the heel, failed to document dietary consumption/nutritional supplements based on per meal intake for one resident with a weight loss, failed to maintain documentation as ordered for blood oxygen level testing per shift for one resident who received routine oxygen, and failed to dress one dependent resident in compression stockings as ordered.

Facility: Keaton Center

Arnold, MO

24-Bed Assisted Living Facility

Date of Notice: October 2009

Owner: Community Treatment Inc.

Operator: Same

Registered Agent: Not Listed

Legal Action: Class I Notice of Noncompliance

Description: The facility failed to correct a fault with the complete fire alarm system.

Facility: Sabbath Manor

St. Louis, MO

64-Bed Residential Care Facility

Date of Notice: October 2009

Owner: Sadaf LLC

Operator: Frasat, LLC

Registered Agent: Bilkiss Cahudhry

Legal Action: Uncorrected Class II Notice of Noncompliance

Description: At the revisit on 09/23/2009, the facility failed to correct deficiencies related to the installation of manual pull stations; installation of interconnected smoke detectors; installation of smoke separation barriers in resident use areas; providing emergency lighting of sufficient intensity and maintaining electrical wiring in good repair.

Facility: Wilbar Boarding Home

St. Louis, MO

49-Bed Residential Care Facility

Date of Notice: October 2009

Owner: William Baker Revocable Trust

Operator: Wilbar Boarding Home, Inc.

Registered Agent: William Baker

Legal Action: Uncorrected Class II Notice of Noncompliance

Description: At the revisit, the facility failed to: Use the personal funds of residents, exclusively for the residents by keeping the resident’s stimulus check as payment for room and board; Purchase a surety bond to ensure protection of resident funds.

Facility: Beauvais Manor Healthcare & Rehab Center

St. Louis, MO

184-Bed Skilled Nursing Facility

Date of Notice: October 2009

Owner: Beauvais Manor Property, LLC

Operator: Beauvais Manor Healthcare & Rehab Center, LLC

Registered Agent: Robin Suydam

Legal Action: Class I Notice of Noncompliance

Description: The facility failed to provide adequate supervision and an environment to mitigate accidents. Staff failed to prevent one confused resident from leaving the facility, unnoticed and unattended. The resident left the facility at 12:30 p.m. and was returned by the police at 4:15 p.m. Staff were unaware the resident left the facility until they were notified by a nearby local business.

Facility: Autumn View Gardens

Ellisville, MO

150-Bed Assisted Living Facility

Date of Notice: October 2009

Owner: Bethesda Foundation

Operator: Same

Registered Agent: C T Corporation System

Legal Action: Uncorrected Class II Notice of Noncompliance

Description: The facility failed to complete an evacuation plan for two of three sampled residents and for two expanded sampled residents. The facility failed to ensure residents were able to evacuate the facility with minimal assistance for two of three sampled residents. The facility failed to ensure community based assessments were completed within five calendar days of admission for one of three sampled residents admitted to the facility. The facility failed to update residents individualized service plans (ISP) for identified care areas and failed to review the ISP with the resident or the resident’s legal representative, for two of six sampled residents and two expanded sampled residents. The facility failed to complete resident’s individualized service plan (ISP) when a significant change in the resident’s condition occurred and failed to review the changes with the resident or the resident’s legal representative, for two expanded sampled residents. The facility failed to obtain physician’s orders for two expanded sampled residents to self administer medications. The facility failed to ensure medications were administered in an appropriate and timely manner, according to acceptable nursing techniques, for four expanded sampled residents.

Facility: The Villas

De Soto, MO

51-Bed Skilled Nursing Facility

Date of Notice: November 2009

Owner: Lierman Family Co. IV LLC

Operator: Heather Nixon

Registered Agent: NA

Legal Action: Class I Notice of Noncompliance

Description: The facility failed to ensure hot water temperatures in resident accessible areas did not exceed 120 degrees Fahrenheit (F). This placed residents at risk of serious burn injury. This condition affected a total of 24 residents who were ambulatory with cognitive impairment, at risk for wandering, had diabetes, peripheral vascular disease, or neuropathies (decreased circulation).

Facility: U-City Forest Manor

St. Louis, MO

120-Bed Skilled Nursing Facility

Date of Notice: November 2009

Owner: U-Forest Place, LLC

Operator: U-City Forest Manor, LLC

Registered Agent: Sharo Shirshekan

Legal Action: Class I Notice of Noncompliance

Description: The facility failed to provide protective oversight by assuring a confused resident with a history of exit seeking behavior, did not leave the facility without supervision. The resident left the facility without staff knowledge and was returned to the facility by local police at approximately 5:00 a.m. The resident was not appropriately dressed or wearing a facility identification wrist band.

Facility: Garden View Care Center Dougherty Ferry

Valley Park, MO

120-Bed Skilled Nursing Facility

Date of Notice: December 2009

Owner: GVCC Partnership

Operator: Garden View Care Center of St. Louis, Inc.

Registered Agent: Scwhra, Inc.

Legal Action: Uncorrected Class II Notice of Noncompliance

Description: The facility failed to thoroughly investigate the circumstances of residents’ falls in a manner which would allow them to implement interventions to reduce falls or prevent accidental injury as a result of the falls and failed to investigate the circumstances which surrounded a resident’s severely bruised hand to prevent another injury of its kind. The facility failed to assess and notify the physician in a timely manner of the development of a pressure ulcer.

Facility: The Westchester House

Chesterfield, MO

159-Bed Skilled Nursing Facility

Date of Notice: December 2009

Owner: Chesterfield Medical Inventors, LLC

Operator: Consolidated Resources Health Care Fund I

Registered Agent: The Corporation Company

Legal Action: Uncorrected Class II Notice of Noncompliance

Description: The facility failed to ensure physicians’ orders were followed and documentation of intake and output was completed for three sampled residents who have tube feeding orders. The facility failed to ensure staff followed and administered the Registered Dietician’s recommendations for two sampled residents who received tube feedings and had pressure ulcers.

Facility: Sunrise on Clayton

Richmond Heights, MO

90-Bed Intermediate Care Facility

Date of Notice: December 2009

Owner: HCP Sun2 Richmond Heights, Missouri LLC

Operator: Sunrise Senior Living Management, Inc.

Registered Agent: C T Corporation

Legal Action: Class I Notice of Noncompliance

Description: The facility failed to provide protective oversight for one of two sampled residents with dementia and a history of elopement. The resident left the facility, undetected by staff, during the night. The resident was found crossing a well traveled road by a passerby, who called the police.