Violation Letter

Missouri Department of Health and Senior Services
P.O. Box 570, Jefferson City, MO 65102-0570
Phone: 573-526-8523
FAX: 573-526-8797
RELAY MISSOURI for Hearing and Speech Impaired 1-800-735-2966 VOICE 1-800-735-2466
Margaret T. Donnelly
Director
MEMORANDUM
Jeremiah
W. (Jay) Nixon
Governor
FOR MATT YOUNGER, SECTION ADMINISTRATOR
SECTION FOR LONG-TERM CARE REGULATION
Carla Jennings, Program Manager ~
Section for Long-Term Care Regulation
Bentleys Extended Care
3060 Ashby Rd
St. Louis, MO 63114
Administrator/Manager -- Gayla Bentley
Operator -- Ashby Road, Inc.
Registered Agent -- Jerome Kraus
-The facility failed to ensure three of twelve sampled residents remained free of accident
hazards through proper assessment of accident prevention interventions, obtaining
physician's orders prior to the use of side rails, and practicing proper transfers.
-The facility failed to provide services to promote the highest practicable physical wellbeing for one of twelve sampled residents. Staff failed to document, continuously
assess and monitor the resident's pain after sustaining three fractures of unknown
origin.
-The facility failed to provide adequate care to residents with indwelling urinary
catheters (tube inserted into the bladder to drain urine) to prevent infections, failed to
obtain orders for the size of the catheters and catheter care and failed to maintain
proper positioning of the catheter tubing and catheter collection drainage bag for two of
two sampled residents with indwelling urinary catheters. The facility identified four
residents with catheters and two of those four residents were included in the sample of
twelve residents.
-The facility failed to provide proper perineal care for three of four sampled dependent
residents observed receiving perineal care.
-The facility failed to follow standard infection control practices by not washing their
hands and/or removing soiled gloves after providing perineal care and to ensure proper
infection control practices were followed when removing soiled linen from a resident's
bed for three of four sampled residents who were observed during care.
www.health.mo.gov
Healthy Missourians for life.
The Missouri Department of Health and Senior Services will be the leader in promoting, protecting and partnering for Health
AN EQUAL OPPORTUNITY I AFFIRMATIVE ACTION EMPLOYER: Services provided on a nondiscriminatory basis.
-The facility failed to keep sprinkler heads free of impediment in order to maintain
sprinkler coverage for the building. This has the potential to affect all of the residents in
the event of a fire.
State Senator -- John Lamping
State Representative -- Tracy McCreery
cc: Teresa Generous, Matt Younger, Larry Smith, CRU, Lieutenant Governor's Office,
Central Files, Health Education Unit, SLCR Region 7, DSDS Region 3, Ombudsman,
BNHA, Family Support Division, DMH, VA Medical Center, LTC Associations, S&C,
DHSS Office Of General Counsel
Missouri Department of Health and Senior Services
P.O. Box 570, Jefferson City, MO 65102-0570
Phone: 573-526-8523
FAX: 573-526-8797
RELAY MISSOURI for Hearing and Speech Impaired 1-800-735-2966 VOICE 1-800-735-2466
Margaret
Director
T. Donnelly
Jeremiah
W. (Jay) Nixon
Governor
Jerome Kraus, Registered Agent
Ashby Road, Inc.
3060 Ashby Rd.
St. Louis, MO 63114
Gayla Bentley, Administrator
Bentleys Extended Care
3060 Ashby Rd
St. Louis, MO 63114
On 04/27/2012, T~e Section for Long-Term Care Regulation (SLCR) completed a
licensure inspection and found Bentleys Extended Care, a 72 bed Skilled Nursing
Facility, not in compliance with Sections 198.003 to 198.096, RSMo, and the standards
established there under. A revisit of the facility was completed by the SLCR staff on
06/25/2012. It was determined the facility is not in substantial compliance in the areas
of Administrative/Resident Care Requirements and Fire Safety Standards as a result of
the uncorrected Class II violations which are listed in the enclosed Statement of
Deficiencies.
The SLCR is hereby issuing Bentleys Extended Care a Notice of Noncompliance in
accordance with Section 198.026.3, RSMo. The SLCR may seek the imposition of any
of the sanctions and remedies provided in Section 198.066 and Section 198.067,
RSMo, or any other action authorized by law. The violations will be presumed to
continue until you notify the SLCR in writing that they have been corrected and the
SLCR staff verifies that they have been corrected. Sign, date, and return the Statement
of Deficiencies with the plan of correction to the SLCR Region 7,815 Olive Street, Suite
10, St. Louis, MO 63101 within ten (10) calendar days of receipt. Your Plan of
Correction MUST NOT INCLUDE THE NAMES OF RESIDENTS. In addition, your plan
of correction should not include other resident specific information such as medical
records. You are required by Section 198.026.6, RSMo, to post a copy of the most
recent inspection report in a conspicuous location in your facility.
The SLCR will send a copy of this Notice of Noncompliance to all concerned federal,
state and local government agencies, as required by Section 198.026.6, RSMo.
Action must be taken to correct the violations set out in the attachment to this notice
within thirty (30) days from the date of delivery of this notice. Representatives of the
SLCR will be conducting a revisit after thirty (30) days to determine whether the
violations in the Statement of Deficiencies have been corrected. If at the time of the
revisit any violations in the Notice of Noncompliance are found not corrected, the SLCR
may seek the imposition of any sanctions and remedies authorized by federal or state
www.health.mo.gov
Healthy Missourians for life.
The Missouri Department of Health and Senior Services will be the leader in promoting, protecting and partnering for Health
AN EQUAL OPPORTUNITY I AFFIRMATIVE ACTION EMPLOYER: Services provided on a nondiscriminatory basis.
1
law or regulations. These sanctions may include the recommendation of a state civil
monetary penalty (CMP) of not less than $250.00 per day for each uncorrected class II
violation, retroactive to the date of the 06/25/2012 revisit.
In accordance with Section 198.545, RSMo, you have one (1) opportunity to question
cited deficiencies through an informal dispute resolution process. To be given such an
opportunity, you are required to send your written request (separate from the plan of
correction), along with the specific deficiencies being disputed, and an explanation of
why you are disputing those deficiencies to:
Mary Collier
Regional Manager
Region 7
815 Olive Street, Suite 10
St. Louis, MO 63101
Nicole Meyer
Primaris
200 N. Keene Street
Columbia, MO 65201
573-817 -8300
[email protected]
Please include a copy of the statement of deficiencies being disputed with your
correspondence to Primaris.
This request must be sent during the same ten (10) calendar days you have for
submitting a plan of correction for the cited deficiencies. The informal dispute resolution
may be conducted by telephone, in writing or in a face-to-face meeting. An incomplete
informal dispute resolution process will not delay the effective date of any enforcement
action.
If you have any questions, please contact Carla Jennings, Program Manager at
573-526-4976.
.
/~
Matty"g~
Section for Long-Term Care Regulation
cc:
Lieutenant Governor's Office
Family Support Division
Department of Mental Health
Central Files
Area Hospitals St. Louis
LTC Associations