legal resources necessary to hold negligent facilities accountable.
Christian Care Home (SFF)
The state of Missouri and the Centers for Medicare and Medicaid Services (CMS) conduct routine investigations, surveys and inspections at least twice a year at every nursing facility statewide. The surveyors identify serious violations, health hazards, and deficiencies through reviews, interviews, and observations. In egregious cases, nursing home regulators may designate the Center as a Special Focus Facility (SFF) and added their name to the federal watch list.
In late 2017, Christian Care Home received a Special Focus Facility designation due to serious violations identified to have occurred at the Center. Likely, the nursing home will remain on the watch list for years and undergo additional surveys and inspections annually. Removal from the watch list will likely require revisions to the facility’s policies and procedures and changes made to the level of care the nursing staff provides. Some deficiencies and violations involving this facility are detailed below.Christian Care Home
This facility is a ‘for profit’ 150-certified-bed Long-Term Care Center providing cares and services to residents of Ferguson and St. Louis County, Missouri. The Home is located at:
800 Chambers Road
Ferguson, MO 63135
In addition to providing around-the-clock skilled nursing care, the facility also offers:
- IV therapy
- Wound care
- Palliative and hospice care
- Rehabilitation to home transition service
- Renal dialysis services
- Restorative nursing
- Memory care
- Physical, occupational, and speech therapies
- Patient-centered therapy
- Electrical stimulation therapy
The state of Missouri and the Centers for Medicare and Medicaid Services have the legal authority to impose monetary penalties against any nursing facility in the state found to have serious violations and safety concerns. These fines are meant to notify the Home that changes must be made immediately to safeguard the health and well-being of every resident.
Over the last three years, Christian Care Home has received two monetary penalties including a $78,000 fine on March 4, 2016, and an $8453 fine on March 1, 2017. Also, Medicare denied two requests for payments from the facility on March 1, 2017, and on September 2, 2017, due to substandard quality of nursing care and hygiene assistance. During the same time frame, surveyors received fourteen formally filed complaints and eight facility-reported issues that all resulted in citations.Current Nursing Home Resident Safety Concerns
The federal government and Missouri care home regulatory agencies routinely update their statewide nursing facility database system. The Medicare.gov website contains historical information and details of dangerous hazards, filed complaints, safety concerns, health violations, opened investigations, and incident inquiries of every facility statewide.
Currently, Christian Care Home maintains an overall one out of five stars compared to all nursing homes in the United States. This ranking includes one out of five stars for health inspections, three out of five stars for staffing issues, and four stars for quality measures. Some serious concerns, violations, and deficiencies involving this facility include:
- Failure to Report and Investigate Acts or Allegations of Abuse, Neglect or Mistreatment of Residents
- Failure to Develop Policies That Prevent Mistreatment, Neglect, or Abuse of Residents
- Failure to Ensure Residents Receive Proper Treatment to Prevent the Development of a Bedsore or Allow an Existing Bedsore to Heal
- Failure to Provide the Right Treatment and Services to Residents Who Have Mental and Psychosocial Problems Adjusting
- Failure to Provide an Environment Free of Accident Hazards
- Failure to Report and Investigate an Act of Abuse, Neglect or Mistreatment of Residents
- Failure to Treat Residents with Dignity and Respect of Individuality
In a summary statement of deficiencies dated March 4, 2016, the state investigator noted the facility’s failure to “intervene, immediately report an allegation of abuse to the Administrator or State Agency.” The staff also failed to “conduct a thorough investigation, and ensure the protection of residents from further potential abuse, when to staff reported the observed a nurse hit a resident.”
The surveyor also noted the facility’s failure “to protect residents after the abuse allegation was made, by allowing the nurse who allegedly slapped the resident to work on the same unit the following shift. The investigator noted that the Director of Nursing was aware of the allegation prior to the night shift. In addition, the facility failed to complete a timely investigation into the abuse allegation and failed to report the results of the investigation within five days of the incident to the State Agency” as required by law.
The investigator reminded the facility of their Abuse Prohibition Protocol dated January 1, 2009, that provided guidance on training, reporting, identifying signs of abuse and how to protect residents.
A review of the resident’s December 2015 Care Plan revealed that the resident has dementia and cognitive loss and provide approaches to providing care including “invite to activities and encourage to participate. Maintain a common, consistent approach. Staff may have to repeat things before the resident understands what is being asked. Make sure the resident has on shoes or non-skid socks to ambulate.…” However, the “Care Plan did not address resident behaviors or provide interventions for how staff should address the resident’s behaviors.
During an interview with the Director of Nursing, it was revealed that Certified Nursing Aides who worked on the night shift on April 29, 2016, reported to a shift nurse that another nurse hit the resident and that they “would be coming to report the allegations to the Director of Nursing. Neither of the Certified Nursing Aides came to her directly to report the allegations, and she did not have anything in writing.” The Director said they “did not report anything [and that the alleged abusive nurse] finished [their] Thursday night shift and work Friday night as well. The Director said she did not report the allegation earlier to the hotline because she worked all weekend.”
Video footage from a camera on the North Unit at the time of the alleged incident showed the nurse entering and exiting the resident’s room. At 4:46 AM, “the video showed [one of the Certified Nursing Aides] was in possession of “a gait belt.” The allegedly abusive nurse “pushed the resident’s wheelchair up the hallway toward [their] room. The resident grabbed the Hoyer Lift station outside the room door.”
The nurse grabbed “the resident’s ham from the lifting and continues pushing the resident into the room. The bar of the Hoyer lift continued swinging even after the resident and nurse went into the room. The nurse remained in the resident’s room until the end of this footage at 5:00 AM.”
In a summary statement of deficiencies dated March 4, 2016, the state investigator noted the facility’s failure “to properly investigate a resident’s allegation of abuse, report the allegation to the State Licensing Agency in accordance with their Abuse and Neglect policy and procedures.” The facility was reminded of their Response and Reporting Policy and Procedure that reads in part:
“It is a policy of this facility to report all alleged or substantiated incidents of abuse or neglect to the appropriate State Agency. Unusual occurrences may be identified as, but not limited to, injuries of unknown origin if there is reasonable cause to believe or suspect that an injury has been abusively inflicted upon a resident. An investigation should be made to determine whether or not bruises, abrasions or other events which occur in the facility are abusive in nature or whether these happenings were simply accidental.” “Each reportable incident must be reported to the State Licensing Agency by telephone within 24 hours with a written report submitted via fax within five days.”
The investigation involved a resident whose Nurses Note from February 15, 2016, revealed that at 3:00 PM, the resident “was alert to person, place, time and situation.” However, by 9:15 PM the same day, the “resident reported that [they] had chronic pain in the left shoulder, but not always.” A body assessment revealed, “left arm swelling.” The resident reported “constant severe and distressing pain present on admission.”
A review of the chair-bound resident’s February 17, 2016, Nurses Note revealed that on February 20, 2016, at 10:00 [no indication of a.m. or p.m.], “the resident complained that a Certified Nursing Aide (CNA) handled [them] roughly when assisting on-and-off the toilet. When addressed, the CNA did not think [they] handled the resident roughly and would apologize.” However, the resident indicated that they “did not want the CNA’s assistance. The resident was monitored throughout the rest of the evening. There was no documentation indicating staff performed an assessment after the resident made allegations against staff for being rushed during care.”
The following day at 8:00 PM, the resident “called family with concerns of the CNA working with [them]. Another CNA was assigned to assist the resident.”
In a summary statement of deficiencies dated March 4, 2016, the state investigator noted the facility’s failure to “implement preventative measures to prevent and heal pressure ulcers. The facility failed to properly complete treatment orders and skin assessments, and also failed to follow up on newly discovered pressure sores.” The deficiency of the nursing staff involved three residents.
In a summary statement of deficiencies dated March 4, 2016, the state investigator noted the facility’s failure “to address the psychosocial needs of two residents….” The staff “did not develop a Plan of Care to obtain psychiatric consult as ordered, or implement non-pharmacological interventions to address the residents’ psychological needs.
In a summary statement of deficiencies dated March 4, 2016, the state surveyor noted the facility’s failure “to provide adequate supervision and protective oversight for one [resident] from the secured unit.” A review of the resident’s July 20, 2015, Comprehensive Care Plan revealed that the “resident is a threat to self and others related to wandering and elopement risk.”
A review of the resident’s February 8, 2016 Nurses Note revealed that the resident had arrived back at the facility at 4:35 PM that afternoon. By 6:18 PM the resident had walked the hallways outside of the facility “a staff member was in the hold the same time as a resident at one time.” A few minutes later the resident was seen wandering in the hallway downstairs and between 6:23 PM and 7:33 PM, the resident “roamed around the maintenance storage room. During this time, [the resident] was seen touching and moving stored items and equipment.”
Further review of the resident’s Nurses Notes indicated that “there was no documentation of the resident’s elopement from the unit or nursing assessment after locating the resident.” The resident’s February 10, 2016, 8:00 PM Nurses Note revealed that the “resident ambulated in the halls and continued to attempt to go out of the exit doors. Staff redirected the resident numerous times.”
Reviewing the facility’s Behavioral Planning Notes dated February 11, 2016, revealed that the resident’s “name was listed, however, there was no documentation of what the resident’s behaviors were or how staff addressed those behaviors. The surveyor interviewed the facility’s Assistant Director of Nursing who said “there was an investigation into the resident’s elopement. The Charge Nurse denied that the resident got off the unit, but the camera showed otherwise. The camera showed the resident exit the through the main door next to the elevation penalty around the hallway [and was] off of the unit [for] about 70 minutes.”
In a summary statement of deficiencies dated September 2, 2016, the state investigator noted the facility’s failure “to conduct a thorough investigation, according to their policy and procedure, for bruise of unknown origin and allegations of staff pushing a resident.” This deficiency by the nursing staff “had the potential to affect [all] residents in the facility.”
A review of the resident’s Progress Notes “dated September 9, 2016, through September 11, 2016, showed no documentation or assessment of a bruise on the resident's forehead.” However, the speech-language Pathologist and Certified Occupational Therapist providing the resident care on September 12, 2016 “observed a yellow-green bruise to the center of the resident’s forehead. The resident was acting impulsively and radically.” The resident reported that they “fell out of bed, then clarified with prompting, nursing pushed [them] out of bed.”
In a summary statement of deficiencies dated September 2, 2016, the state investigator noted the facility’s failure “to care for residents in a manner an environment that maintained dignity and honored their preferences.” This failure involved the staff “talking negatively about resident care in front of the residents and by [a failure] to provide a pleasant dining experience when staff left residents in the Assistant Feeding Dining Room with the lights off and no radio on.”
The state investigator interviewed the facility’s Director of Nursing on the afternoon of September 1, 2016. During the interview, it was revealed that “residents are in the Assistant Dining Room because they need help eating and are at risk for choking. Staff to provide a pleasant environment and sitting in the dark is not appropriate.”
If you believe that your grandparent, parent or spouse died prematurely or suffered serious injury while a patient at Christian Care Home, hiring a personal injury attorney can be a wise decision. A lawyer working on your behalf can handle the entire case including gathering evidence, investigating your claim, speaking to claims adjusters, negotiating an out of court settlement, and presenting evidence at trial, if necessary.
You never need to make any upfront payment for legal services because personal injury law firms accept all nursing home neglect cases through contingency fee agreements. This arrangement means the fees are paid only after your lawyers have successfully resolved your claim for compensation to ensure your family receives financial compensation for your injuries.