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Missouri Long-term Care Facility Notices of Non-Compliance 2007

2007 Nursing Home Non-Compliance by Region: 1. Southwest Region 2. Southeast Region 3. Kansas City Region 4. Northwest Region 5. Northeast Region 6. Central Region 7. St. Louis Region

CENTRAL REGION
Facility: West Woods Care Center, Inc. Bourbon, MO 12-Bed Residential Care Facility Date of Notice: January 2007	Owner: Converse, Richard & Audrey Operator: Not Listed Registered Agent: Not Listed	Legal Action: DENIAL OF LICENSURE
Description: The operator has failed to provide a complete application, including all required attachments, demonstrating financial capacity to operate the facility. The operator failed to provide additional information related to the application within (10) working days of the change or of SLTC's request.
Facility: West Woods Care Center, Inc. Bourbon, MO 12-Bed Residential Care Facility Date of Notice: February 2007	Owner: Converse, Richard & Audrey Operator: Not Listed Registered Agent: Not Listed	Legal Action: RECISSION OF DENIAL AND RE-DENIAL OF APPLICATION FOR LICENSE
Description: The operator has failed to provide a complete application, including all required attachments, demonstrating financial capacity to operate the facility. The operator failed to provide additional information related to the application within 10 working days of the change or of SLTC's request. The facility and the operator are not in substantial compliance with the provisions of sections 198.003 to 198.096 and the standards established thereunder. The facility has had a history of chronic noncompliance with SLCR standards between August, 2004 and present as identified in Statements of Deficiencies previously provided to the facility and the Statement of Deficiencies enclosed with this letter. (Letter on file with MCQC).
Facility: Ridgeway Residential Care Sullivan, MO 20-Bed Residential Care Facility Date of Notice: February 2007	Owner: Turner, Deborah J. Operator: Deborah J. Turner Registered Agent: Not Listed	Legal Action: Uncorrected Class II Notice of Noncompliance
Description: A complaint investigation was completed on 11/28/06. The facility was not in substantial compliance with participation requirements. A revisit was completed on 2/14/07. The facility failed to have a designated administrator who is currently licensed as a nursing home administrator. The administrator's license expired 6/30/06.
Facility: South Pointe Assisted Living by Americare Washington, MO 50-Bed Assisted Living Facility Date of Notice: March 2007	Owner: Not Listed Operator: Washington Residential, LLC Registered Agent: Husch Registered Agent, Inc.	Legal Action: Uncorrected Class II Notice of Noncompliance
Description: An inspection was completed on 12/15/06. The facility was not in substantial compliance with participation requirements. A revisit was completed on 2/16/07. The facility failed to complete community based assessments for one of six residents reviewed and had not completed 12 to 15 additional residents' community based assessments. Also, the facility staff failed to develop individual service plans for three residents.
Facility: Westbrook Terrace Assisted Living by Americare Jefferson City, MO 31-Bed Assisted Living Facility Date of Notice: May 2007	Owner: Not Listed Operator: Jefferson City Residential, LLC Registered Agent: Husch Registered Agent, Inc.	Legal Action: Class I Notice of Noncompliance
Description: Based on resident and staff interview and record review, staff failed to safely evacuate four residents (Residents #1, #2, #3, and #4) from the building during an unplanned fire alarm. The facility census was 22 residents.
Facility: Ashbury Heights of Jefferson City Jefferson City, MO 12-Bed Residential Care Facility Date of Notice: June 2007	Owner: Bristol Care, Inc. Operator: Same Registered Agent: David C. Furnell	Legal Action: Uncorrected Class II Notice of Noncompliance
Description: A licensure inspection was completed on 4/10/07. The facility was not in substantial compliance with participation requirements. A revisit was completed on 6/04/07. The facility staff failed to ensure a fire alarm device was available in one resident's room who could not hear the fire alarm when it activated in the main facility.
Facility: Columbia Healthcare Center Columbia, MO 97-Bed Skilled Nursing Facility Date of Notice: July 2007	Owner: Seniortrust of Columbia, LLC Operator: Same Registered Agent: National Registered Agents, Inc.	Legal Action: Class II Notice of Noncompliance
Description: A complaint investigation was completed on 7/23/07. The facility was not in compliance with participation requirements. The facility staff failed to maintain one dependent and quadriplegic resident's bed in a proper position to ensure safety and prevent the resident from falling. Staff checked on the resident on 7/17/07 at 2:45 p.m. and the resident was confused. Staff reoriented the resident and left the resident room. The resident was lying on his/her left side in the bed. At 3:30 p.m., staff returned to the resident room and found the resident on the floor on the right side of his/her bed, with his/her head resting on a bedside night stand. The resident's upper bedrails were raised to the one-quarter height and the resident's arm was tangled in the right upper bedrail. The certified nurse aide said he/she reported to staff the resident's bed was broken, it's up too high and will not come down to a normal position, but staff did not address it. Observation of the resident revealed the bed in the highest position, the mattress sat approximately three feet from the floor and was made of slick nylon type material.
Facility: Ridgeway Residential Care Sullivan, MO 20-Bed Assisted Living Facility Date of Notice: August 2007	Owner: Turner, Deborah J. Operator: Deborah J. Turner Registered Agent – Not Listed	Legal Action: Uncorrected Class II Notice of Noncompliance
Description: A licensure inspection was completed on 5/25/07. The facility was not in substantial compliance with participation requirements. A revisit was completed on 8/02/07. The facility staff failed to take corrective action in the following areas: Complete a premove-in screening for one newly admitted resident; develop and implement individualized service plans for three residents outlining the residents needs and preferences; provide activities for the residents or inform residents in advance of the activities to be held; to provide individualized service plans to ensure three residents received proper care according their needs; provide residents with a written statement of the current balance and all transactions in their resident trust account for eight residents.
Facility: Jefferson City Nursing and Rehab Jefferson City, MO 120-Bed Skilled Nursing Facility Date of Notice: August 2007	Owner: Not Listed Operator: Jefferson City Nursing and Rehab Center, LLC Registered Agent: CSC—Lawyers Incorporating Service Company	Legal Action: Class II Notice of Noncompliance
Description: A complaint investigation was completed on 7/26/07. The facility was not in substantial compliance with participation requirements. Facility staff failed to contact one resident's physician and communicate critical laboratory results, which delayed treatment. The resident experienced a serious health decline, which required hospitalization. In addition the facility staff failed to develop and implement a system for reporting residents abnormal laboratory results to their physicians in a timely manner. On 7/13/07 at 1:55 P.M., laboratory staff notified the facility with a printed report of the resident's potassium level of 7.1 identified by laboratory staff as critically high (normal range 3.5-5.0). Facility staff did not notify the resident's physician of the critically high results. Staff documented on 7/18/07 the resident's physician contacted the facility about the critical potassium level. The resident experienced a decline in condition including altered mental status and rapid irregular pulse rate. Staff documented the resident's heart rate of 166 then 27 then 190 in a matter of a minute.
Facility: Bristol Manor of Eldon Eldon, MO 12-Bed Residential Care Facility Date of Notice: December 2007	Owner: Bristol Care, Inc. Operator: Same Registered Agent: David C. Furnell	Legal Action: Class I Notice of Noncompliance
Description: The facility failed to provide oversight to one resident who left the facility unsupervised through an alarmed side door, fell outside on an ice/snow covered ramp, and required hospitalization for hypothermia. The facility reported to corporate maintenance staff in July 2007 that the facility staff could not hear the door alarm from the kitchen. After corporate maintenance staff worked on the door alarm it still could not be heard from the kitchen.

KANSAS CITY REGION
Facility: Carondelet Manor Kansas City, MO 162-Bed Skilled Nursing Facility Date of Notice: January 2007	Owner: Carondelet Health Operator: Carondelet Long Term Care Facilities, Inc. Registered Agent: Timothy O. Kristl		Legal Action: Uncorrected Class II Notice of Noncompliance
Description: The facility failed to ensure staff followed physician orders for two residents. One resident had been readmitted to the facility after treatment in the hospital for anemia. Staff failed to administer the resident iron and failed to clarify physician orders and continued to administer the resident aspirin (prevents blood from clotting). Staff failed to release a second resident's restraint during meals as ordered by the physician. The facility census was 119 residents.
Facility: Country Oak Village Grain Valley, MO 32-Bed Residential Care Facility Date of Notice: January 2007		Owner: Not Listed Operator: SWBG Development, Inc. Registered Agent: Ron Stuart	Legal Action: Uncorrected Class II Notice of Noncompliance
Description:  At the second revisit, the facility failed to: Provide a safe exterior for residents to evacuate the facility to a safe distance in all weather conditions from two exits. Ensure that one smoke partition door completely closed upon activation of the fire alarm system to prevent the passage of smoke. The facility census at the time of the revisit was 16 residents.
Facility: New Mark Care Center Kansas City, MO 191-Bed Skilled Nursing Facility Date of Notice: February 2007		Owner: New Mark Care Center, Inc. Operator: NMCC, Inc. Registered Agent: Eugene J. Feldhausen	Legal Action: Class I Notice of Noncompliance
Description: The facility failed to assure staff followed policies and implement emergency procedure for one resident, when two licensed staff found the resident without a pulse or respirations and failed to initiate cardiopulmonary resuscitation (CPR).
Facility: Campbell Care Kansas City, MO 27-Bed Residential Care Facility Date of Notice: February 2007		Owner: Not Listed Operator: Davis Health Care, Inc. Registered Agent: Danny L. Davis	Legal Action: Uncorrected Class II Notice of Noncompliance
Description: The facility failed to correct violations in the area of Physical Plant requirements as the facility failed to keep resident rooms and resident use bathrooms clean on a daily basis. Other deficiencies included: Fire Safety requirements: The facility failed to ensure all smoke detectors in the facility were in working order and failed to ensure that all sprinkler heads were free of corrosion and were not obstructed. Physical Plant requirements: The facility failed to ensure the floor around the ice machine was in good repair as the floor was soft and sank when walked on; failed to ensure all walls, ceilings and windows were cleaned and in good repair; and failed to ensure all vents and fans were clean and in good repair. General Sanitation requirements: The facility failed to prevent rodents and insects in resident rooms, the dining room, the furnace room and the resident use ice chest. Sanitation Requirements for Food Service: The facility failed to ensure food contact surfaces were cleaned; failed to ensure the inside of the ice machine was free of mildew; failed to clean and maintain non-food contact surfaces and equipment; and failed to use the proper concentration of chemicals when sanitizing dishes.
Facility: Raymore Health Care Raymore, MO 128-Bed Skilled Nursing Facility Date of Notice: February 2007		Owner: Raymore Real Estate LLC Operator: Raymore Care Center LLC Registered Agent: Raymore Healthcare, Inc.	Legal Action: Class I Notice of Noncompliance
Description: The facility staff failed to assess, monitor and notify the physician and family members after one resident had an unwitnessed fall. On 1/9/07 at 1:50 p.m., staff found the resident on the floor in his/her room after an unwitnessed fall from his/her wheelchair. Except for immediately after the fall, staff did not monitor the resident and did not complete neurological checks according to the facility's policy. On 1/10/07 at approximately 4:15 p.m., a family member noted the resident had a decreased level of consciousness and complained of a headache. Staff transferred the resident to the hospital on 1/10/07. Hospital records showed the neurologist who examined Resident #29 at the hospital said the resident had a large subdural hematoma most likely trauma induced. The resident died at the hospital on 1/11/07.
Facility: Edgewood Manor Nursing Home Raytown, MO 60-Bed Skilled Nursing Facility Date of Notice: February 2007		Owner: Not Listed Operator: Deaconess Long Term Care of MO, Inc. Registered Agent: The Corporation Company	Legal Action: Uncorrected Class II Notice of Noncompliance
Description: The facility failed to correct violations in the following areas: Fire Safety Standards: Facility staff failed to ensure all sprinkler heads have an escutcheon plate that fits securely against walls and ceilings to seal openings around sprinkler pipes in the visitor bathroom, 600 hall shower room, and the maintenance shop. Physical Plant Requirements: Facility staff failed to ensure all resident room doors completely close and latch to resist the passage of smoke, failed to maintain the smoke barrier between the skilled nursing facility and the residential care facility free from penetrations and failed to provide exit discharge areas with two sources of lighting so if one source of lighting failed, affected two outside exit discharge areas.
Facility: Blue Hills Rest Home, Inc. Independence, MO 44-Bed Residential Care Facility Date of Notice: February 2007		Owner: Not Listed Operator: Blue Hills Rest Home, Inc. Registered Agent: Ethel Marie Dunham	Legal Action: Uncorrected Class II Notice of Noncompliance
Description: The facility failed to have a sprinkler system installed in all areas of the facility.
Facility: Guardian Angel Residential Care Raytown, MO 12-Bed Residential Care Facility Date of Notice: February 2007		Owner: Davis, Ralene E. Operator: Ralene Davis Registered Agent: None	Legal Action: Uncorrected Class II Notice of Noncompliance
Description: The facility failed to comply with city codes that require facilities with occupancy greater than eight, be fully sprinklered. As of 1/25/07, the facility had not installed a sprinkler system. The facility census was 11 residents.
Facility: The Essex of Grain Valley Grain Valley, MO 12-Bed Residential Care Facility Date of Notice: February 2007		Owner: Not Listed Operator: Bristol Care, Inc. Registered Agent: David C. Furnell	Legal Action: Uncorrected Class II Notice of Noncompliance
Description: The facility failed to ensure staff obtained daily blood pressure and pulse readings, weekly weights and failed to administer medication in the proper amount at the proper times according to the physician's orders. The facility also failed to: Keep the dryer lint traps clean to prevent a fire hazard and failed to develop a fire evacuation plan that included all the required elements. Maintain toilets in resident rooms in working order. Ensure resident rooms were orderly and clean. Ensure ceramic cook top surfaces were in good repair and cleanable. Ensure resident's individual over-the-counter medications were labeled with the resident's name. Properly store refrigerated, hazardous foods to prevent potential contamination of other foods and failed to properly label refrigerated and dry foods.
Facility: Heartland of Willow Lane Butler, MO 98-Bed Skilled Nursing Facility Date of Notice: February 2007		Owner: Health Care & Retirement Corporation of America Operator: Same Registered Agent: C T Corporation System	Legal Action: Class I Notice of Noncompliance
Description: The facility staff failed to inform the physician on an ongoing basis of Resident #1's decline in condition. On 1/5/07, laboratory results indicated Resident #1 had clinical signs of dehydration, renal failure and anemia. Staff failed to notify the physician on an ongoing basis when Resident #1 had decline in respiratory status with decreased oxygen saturation levels and required use of oxygen, when the resident had decreased intake of food and fluids and of the family's request for the resident to receive intravenous fluids. On 1/8/07, Physician A ordered staff to send the resident to the hospital for a blood transfusion. The resident arrived at the hospital at 11:45 a.m. At 1:25 p.m., hospital Physician B pronounced Resident #1 dead and said the resident appeared thin, had no fatty tissue, his/her ribs were visible and that the resident appeared dehydrated. The facility census was 68 residents.
Facility: Foxwood Springs Living Center Raymore, MO 108-Bed Skilled Nursing Facility Date of Notice: February 2007		Owner: FITNBA Foxwood Group LLC Operator: BLC-Foxwood Springs, LLC Registered Agent: C T Corporation System	Legal Action: Uncorrected Class II Notice of Noncompliance
Description: 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. A facility licensed practical nurse failed to follow standards of practice and the facility's policy when inserting an indwelling catheter in one resident with prostate cancer. When the resident complained of pain and the LPN met resistance during the catheterization, the LPN did not stop the procedure. Nursing staff did not consistently document assessments of Resident #2's urine. Within 24 hours of the procedure, the physician ordered staff to transfer Resident #2 to the local emergency room for evaluation and treatment of bloody urine. The facility census was 104 residents.
Facility: Garden Valley Manor & Rehab, LLC Kansas City, MO 150-Bed Skilled Nursing Facility Date of Notice: March 2007		Owner: Garden Valley Manor & Rehab, LLC Operator: Same Registered Agent: Sharo Shirshekan	Legal Action: Class I Notice of Noncompliance
Description:  The facility failed to ensure one of 15 residents who received mechanical soft diets received the appropriate texture of meat, monitor the resident for risk factors of difficulty with chewing and perform the Heimlich maneuver in a timely manner when the resident became unresponsive and cyanotic around the lips and fingernails. The resident died on 2/7/07 at the hospital from aspiration pneumonia. The facility failed to ensure one of 15 residents who were on mechanical soft diets received the appropriate texture of meat as ordered by the physician.
Facility: The Summit Kansas City, MO 60-Bed Skilled Nursing Facility Date of Notice: March 2007		Owner: Not Listed Operator: The Summit Registered Agent: Summit Nursing Home, Inc.	Legal Action: Class I Notice of Noncompliance
Description: Based on observation, interview, and record review, the facility failed to provide adequate supervision and oversight for one sampled by not determining the whereabouts of the resident who signed out of the facility on 2/22/07 and had not returned by 3/9/07. The facility failed to report the resident's disappearance to the Elder Abuse Hot Line, the resident's next of kin, and the police. The facility also failed to provide supervision and oversight to prevent elopement for one sampled resident, and failed to develop interventions for the prevention of falls following a fall for four sampled residents.
Facility: Wood Oaks Independence, MO 30-Bed Residential Care Facility Date of Notice: March 2007		Owner: Wood Oaks, Inc. Operator: Same Registered Agent: Not Listed	Legal Action: Uncorrected Class II Notice of Noncompliance
Description:  A licensure inspection was completed on 12/04/06. The facility was not in substantial compliance with participation requirements. A revisit was completed on 2/28/07. The facility failed to ensure there was one-hour separation between a hazardous area, furnace room, and the rest of the building by using inappropriate fire stopping material on ceiling spaces in the furnace room. Facility staff used expandable yellow foam on the ceiling spaces in the furnace room. In addition, the facility staff failed to maintain the exit ramp and adjoining structures from the south exit in good repair. The facility staff failed to make needed repairs to the kitchen and dining room floors.
Facility: Leona House Kansas City, MO 7-Bed Assisted Living Facility Date of Notice: March 2007		Owner: W.H.E. Homes, LLC Operator: Same Registered Agent: Capitol Corporate Services, Inc.	Legal Action: Uncorrected Class II Notice of Noncompliance
Description: The facility failed to assure that no employee was on duty with responsibility for the oversight of residents for more than eighteen hours per day. The facility failed to assure appropriately trained staff completed the community based resident assessments. The facility failed to provide adequate staffing for one resident who displayed periods of agitation, wandering and was resistive with staff. The facility failed to have an individual emergency evacuation plan as part of the service plan.
Facility: Butterfly Haven Kansas City, MO 12-Bed Residential Care Facility Date of Notice: March 2007		Owner: Cameron, Mark & Scarlett Operator: Cameron, Scarlett Registered Agent: Not Listed	Legal Action: Class I and Uncorrected Class II Notice of Noncompliance
Description: Class I Violations – The facility failed to ensure one resident could make a path to safety. The facility continued to care for the same resident after the resident's condition declined and the resident required a higher level of care. Uncorrected Class II Violations – Fire Safety – The facility failed to provide the surveyors access to all areas of the facility; to update the facility floor plan to indicate location of all fire extinguishers; and to ensure three of three fire exits from the second floor and accessible to residents, were free of obstructions. Physical Plant – The facility failed to have the facility's electrical wiring inspected at least every two years. Administration and Resident Care – The facility failed to conduct checks of the employee disqualification list and to complete background checks for newly hired staff; to maintain complete employee records for two staff; and to document monthly reviews of residents' needs and conditions. General Sanitation – The facility failed to maintain walls in good repair and failed to ensure kitchen light covers were clean.
Facility: Country House Independence, MO 15-Bed Assisted Living Facility Date of Notice: April 2007		Owner: Skyview Manor, Inc. Operator: Same Registered Agent: Robbie Vaughan	Legal Action: Uncorrected Class II Notice of Noncompliance
Description: The facility failed to prevent the storage of unnecessary combustibles in one storage area on the second floor and in the attic area, potentially affecting four residents. The facility failed to ensure sprinkler heads were maintained free of corrosion and obstructions, potentially affecting four residents in the facility. The facility failed to ensure an electrical inspection was conducted every two years by a qualified electrician, affecting all residents of the facility.
Facility: Cedar Valley Health Center Raytown, MO 154-Bed Skilled Nursing Facility Date of Notice: April 2007		Owner: Not Listed Operator: Deaconess Long Term Care of MO, Inc. Registered Agent: The Corporation Co.	Legal Action: Class I Notice of Noncompliance
Description: The facility failed to ensure one resident (Resident #1) was free from abuse when the facility administrator took away the resident's electric wheelchair on 3/14/07 and alleged the resident assaulted others with the wheelchair. The facility census was 103.
Facility: Andrews Way Raytown, MO 12-Bed Residential Care Facility Date of Notice: April 2007		Owner: Barbara L. Andrews Memorial Housing Operator: New Horizons Assistance Corp. Registered Agent: Sharon Turner-Jackson	Legal Action: Uncorrected Class II Notice of Noncompliance
Description: The facility failed to ensure the window curtains in the resident rooms and the manager's office were flame resistant. The facility failed to ensure hot water temperatures did not exceed 120 degrees. The facility census was 10 residents.
Facility: Holmesdale Healthcare & Rehabilitation Center Kansas City, MO 100-Bed Skilled Nursing Facility Date of Notice: April 2007		Owner: Holmesdale Properties, LLC Operator: Holmesdale Healthcare & Rehabilitation Registered Agent: Not Listed	Legal Action: Uncorrected Class II Notice of Noncompliance
Description: The facility failed to follow physician orders and administer medications and treatments, including pain medication, as ordered and failed to obtain a pulse before administering medication as ordered. The facility also failed to obtain a physician's order before administering medication. The facility census was 75.
Facility: Blue Ridge Nursing Home Kansas City, MO 38-Bed Intermediate Care Facility Date of Notice: May 2007		Owner: Carroll, Frank Jr. & Lisa M. Operator: Carroll Care Centers, Inc. Registered Agent: Jeffrey L. Lucas	Legal Action: Uncorrected Class II Notice of Noncompliance
Description:  The facility failed to maintain the banister from the first floor to the second floor in good repair.
Facility: Pleasant Valley Manor Care Center Liberty, MO 102-Bed Skilled Nursing Facility Date of Notice: May 2007		Owner: Pleasant Valley Manor, Inc. Operator: Same Registered Agent: Hal Juckette	Legal Action: Class I Notice of Noncompliance
Description: The facility failed to use safe practice when they altered a seat-belt restraint. Staff could only release the “pin lock” restraint by using a pointed device. The “pin lock” restraint affected four residents. Observation showed the facility used full-length bed rails on two residents.
Facility: White Oak Manor Kansas City, MO 150-Bed Skilled Nursing Facility Date of Notice: June 2007		Owner: White Oak Manor, LLC Operator: Same Registered Agent: Sharo Shirshekan	Legal Action: Class I Notice of Noncompliance
Description: The facility failed to develop and implement policies and procedures to protect residents from abuse when the hospital emergency room physician notified the facility that someone at the facility had assaulted and/or possibly raped one resident. The facility failed to immediately put measures in place to protect other residents from potential abuse when one resident was identified as a victim of abuse. The facility also failed to assure staff transferred one resident in a safe manner.
Facility: Turning Point Group Home Independence, MO 12-Bed Residential Care Facility Date of Notice: June 2007		Owner: Independent Residential Services Inc. Operator: Same Registered Agent: David H. Cook	Legal Action: Uncorrected Class II Notice of Noncompliance
Description: The facility failed to: Ensure resident rooms were neat and cleaned daily. Obtain a physician's order for oxygen use. Label and date opened foods and failed to ensure food is protected from potential contamination.
Facility: The Oaks Kansas City, MO 62-Bed Residential Care Facility Date of Notice: June 2007		Owner: Not Listed Operator: Tall Timbers, LLC Registered Agent: Gordon Goodman	Legal Action: Uncorrected Class II Notice of Noncompliance
Description: The facility failed to: Ensure the building was maintained in good repair. Ensure the hot water temperatures were maintained at temperatures between 105 and 120 degrees Fahrenheit. Follow physician orders for lab work for three residents. Maintain fans, vents, light fixture covers in clean condition. Ensure the facility manager attended at least one Department of Health and Senior Services approved, continuing education workshop each year. Clean and maintain carpets in resident rooms, common areas and hallways.
Facility: Rosewood Health Center Independence, MO 300-Bed Skilled Nursing Facility Date of Notice: July 2007		Owner: Gardner, Lea Operator: The Groves Registered Agent: Karen E. Minton	Legal Action: Class I Notice of Noncompliance
Description: The facility failed to provide appropriate supervision, assistive devices and care and treatment for one resident. The facility failed to adequately supervise one resident, with a history of elopement, from leaving the facility. At the time of admission on 6/12/07, the facility knew the resident to be an elopement risk and placed the resident on the locked unit. After admission, the resident made several unsuccessful attempts to elope. On 6/28/07, two staff in an office saw the resident outside walking around in the rain and the staff caring for the resident didn't know the resident was gone. The Vice President of Nursing told the surveyors the resident had eloped and may have been gone 20-25 minutes. A surveillance camera tape showed the resident going out the locked unit doors with a visitor at 12:26 p.m. the two staff who saw the resident outside in the rain said staff brought the resident back into the facility sometime between 12:35 p.m. and 12:50 p.m.
Facility: Golden Years Harrisonville, MO 132-Bed Skilled Nursing Facility Date of Notice: July 2007		Owner: Deaconess Long Term Care of Missouri, Inc. Operator: Same Registered Agent: Deaconess Long Term Care of MO, Inc.	Legal Action: Uncorrected Class II Notice of Noncompliance
Description: The facility failed to maintain safe water temperatures between 105 degrees Fahrenheit (F) and 120 F, and which did not exceed 120 F at water fixtures on the 300 hall resident-use wing, potentially affecting 14 residents who reside on the 300 hall.
Facility: Beacon Hill Nursing Home Kansas City, MO 37-Bed Residential Care Facility Date of Notice: July 2007		Owner: Davis Realty Holdings, LLC Operator: Davis Health Care, Inc. Registered Agent: Danny L. Davis	Legal Action: Uncorrected Class II Notice of Noncompliance
Description: The facility failed to maintain rooms, carpets, window blinds, ceilings and other equipment in good repair and in accordance with the construction and fire safety rules in effect at the time of initial licensing.
Facility: Clara Manor Nursing Home Kansas City, MO 90-Bed Intermediate Care Facility Date of Notice: July 2007		Owner: MM Properties, Inc. Operator: Clara Manor Nursing Home, Inc. Registered Agent: Gary L. Marvine	Legal Action: Uncorrected Class II Notice of Noncompliance
Description: The facility failed to ensure the bathrooms on the lower level of the facility were open and maintained in good repair for residents' use. The facility failed to maintain the ceiling in the sprinkler room to prevent the passage of smoke in the event of a fire emergency. The facility failed to maintain four room doors to ensure the doors latched when closed to prevent the passage of smoke in the event of a fire emergency, potentially affecting eight residents residing in the rooms. The facility failed to ensure the sprinkler system was continuously maintained in reliable operating condition when it did not replace three sprinkler system gauges, potentially affecting all residents.
Facility: Leona House Kansas City, MO 7-Bed Assisted Living Facility Date of Notice: July 2007		Owner: W.H.E. Homes, LLC Operator: Same Registered Agent: Capitol Corporate Services, Inc.	Legal Action: Uncorrected Class II Notice of Noncompliance
Description: The facility failed to ensure the smoke wall in the facility would not allow the passage of smoke from one section of the building to the other in the event of a fire. The facility also failed to have the smoke door separating the two sections of the smoke wall close with activation of the fire alarm.
Facility: Johnson County Care Center Warrensburg, MO 87-Bed Skilled Nursing Facility Date of Notice: August 2007		Owner: R M Properties, Inc. Operator: Johnson County Care, Inc. Registered Agent: Gary L. Marvine	Legal Action: Class I Notice of Noncompliance
Description: Based on observation, record review and interview, the facility staff failed to provide adequate supervision, failed to develop and implement appropriate interventions and failed to ensure staff properly operated elevators to and from the facility's locked/secured unit to prevent one resident's elopement from the facility. The facility identified one resident (Resident #1) as a high risk for elopement and placed the resident on the locked unit. The resident's room was located next to the back elevator. Resident #1 was not to be off the unit without one to one staff supervision. On 8/11/07, Resident #1 left the facility without staff knowledge and was unaccounted for approximately two hours. Staff interviews revealed staff failed to remove the elevator key properly and caused the elevator door to randomly open and close. Resident #1 said he/she got on the back elevator and left the building on 8/11/07. The census on the locked unit was 40 residents. The facility census was 81 residents.
Facility: Woodbine Healthcare and Rehab Center Gladstone, MO 300-Bed Skilled Nursing Facility Date of Notice: August 2007		Owner: Not Listed Operator: Woodbine Healthcare, LLC Registered Agent: CSC-Lawyers Incorporating Service Company	Legal Action:  Class II Notice of Noncompliance
Description: The facility failed to conduct an ongoing assessment, complete documentation of the resident's condition and implement measures to prevent one resident, who the facility identified at risk for skin breakdown due to edema of the right lower extremity and diabetes from developing blisters on the right heel, posterior (back) calf and knee. The facility failed to maintain the sprinkler heads (mechanical devices connected to an automatic sprinkler system that are designed to activate and dispense water during fire) in reliable operating condition. Staff did not keep sprinkler heads on all halls in the attic space free of fallen insulation.
Facility: Maywood Manor Independence, MO 24-Bed Residential Care Facility Date of Notice: August 2007		Owner: Stroetker, John & Pamela Operator: Stroetker Diversified Inc. Registered Agent: Michael J. Gleason	Legal Action: Class II Notice of Noncompliance
Description:  Based on record review and interview, facility staff failed to administer the correct medications, failed to document the medication error, failed to inform the next shift of the medication error, failed to follow physician's orders to monitor the resident, inaccurately documented checks of the resident throughout the night, and to appropriately respond to an (sic) change in  condition/emergency situation affecting one resident (Resident #1). On 8/14/07 at 8:00 P.M., staff administered Resident #1 16 medications ordered for another resident. The physician ordered staff to “watch” resident. The evening staff did not inform the night shift staff of the medication error or the physician's order. The night shift staff failed to accurately document checks of the resident throughout the night. Between 5:30 A.M. and 6:00 A.M., the night shift staff observed Resident #1 on the floor and not moving but did not check the resident. The day shift staff checked the resident about 6:00 A.M. and found the resident unresponsive with shallow respirations and a faint pulse. Staff called 911 who transported the resident to the emergency room. The ER physician pronounced the resident's death at 6:47 A.M. The facility census was 20 residents.
Facility: Riverside Nursing and Rehabilitation Center, LLC Kansas City, MO 180-Bed Skilled Nursing Facility Date of Notice: August 2007		Owner: Not Listed Operator: Riverside Nursing and Rehabilitation Center, LLC Registered Agent: CSC-Lawyers Incorporating Service Company	Legal Action: Uncorrected Class II Notice of Noncompliance
Description: The facility failed to maintain one battery-powered emergency lighting unit operational on the Shackleford (SC) Unit. This had the potential to affect 21 residents who lived on the SC Unit.
Facility: Silver Oak Senior Living Butler, MO 57-Bed Residential Care Facility Date of Notice: August 2007		Owner: HR Acquisition Corp Operator: Silver Oak Senior Living Management Co., LC Registered Agent: Ken Hanne	Legal Action: Uncorrected Class II Notice of Noncompliance
Description: The facility failed to ensure: the fire door at the entrance to Butterfly Hall off of the living room area of the facility prevented the passage of smoke from one section to another. At the revisit, there was a ½ inch gap at the top of the door. The kitchen door was equipped with a self-closing device to provide a one-hour fire separation in hazardous areas.
Facility: Deaconess Specialty Care Center Kansas City, MO 116-Bed Skilled Nursing Facility Date of Notice: August 2007		Owner: Deaconess Long Term Care of Missouri, Inc. Operator: Same Registered Agent: The Corporation Co.	Legal Action: Uncorrected Class II Notice of Noncompliance
Description: A survey was completed on 4/18/07. The facility was not in substantial compliance with participation requirements. A revisit was completed on 7/25/07. The facility staff failed to ensure wood paneling used at various nurses' stations, on counters and walls had a flame spread rating of Class A or B as required in the National Fire Prevention Association (NFPA) Life Safety Code Standard. The facility staff failed to ensure the wood material installed and treated with a flame retardant was tested and did not exceed a flame spread of 25. Facility staff failed to maintain the carpet in the second floor dining room free of holes and stains. In addition facility staff failed to serve food items at the proper serving temperature of 120 degrees Fahrenheit.
Facility: Life Care Center of Grandview Grandview, MO 172-Bed Skilled Nursing Facility Date of Notice: September 2007		Owner: Grandview Medical Investors, LLC Operator: United Investors Limited Registered Agent: C T Corporation System	Legal Action: Class II Notice of Noncompliance
Description: The facility failed to ensure: One resident received all nutrition and medications through a feeding tube inserted into the stomach. The physician gave an order for staff to elevate the head of the bed greater than 30 degrees (to prevent aspiration of stomach contents). On 8/23/07, laboratory personnel found the resident lying flat in bed with a frothy white substance coming from the resident's mouth. The resident was transferred to the hospital. The hospital physician determined the resident had aspiration pneumonia, health care associated. A second resident had multiple sclerosis. The resident had a suprapubic (a tube inserted directly into the bladder) catheter with occasional urinary incontinence. The resident wore adult briefs and was dependent on staff for personal hygiene care. On 9/1/07, the licensed charge nurse instructed the nurse's aide to clean the resident up because of a foul odor. The nurse's aide found maggots in the resident's pubic area, in a wound on the underside of the penis and on the bed sheets. The resident said he did not know he had maggots until staff told him, as he had no feeling. The physician ordered staff to treat the resident with RID. Staff did not document in the nurse's notes or on the treatment record that staff had completed the treatment. The corporate nurse and the director of nursing said if staff did not document the treatment as done, the treatment was not done.
Facility: Rosewood Health Care Independence, MO 300-Bed Skilled Nursing Facility Date of Notice: September 2007		Owner: Not Listed Operator: The Groves Registered Agent: Karen E. Minton	Legal Action: Uncorrected Class II Notice of Noncompliance
Description: Based on observation, record review, and interview, the facility staff: Failed to follow physician's orders and failed to document they had administered medication and treatments as ordered for five residents. Staff failed to obtain urine for laboratory testing to rule out a urinary tract infection. Staff failed to document blood sugar checks were completed and failed to document the results; failed to administer and/or document the amount of insulin administered; failed to obtain and/or document blood pressure results as ordered; and failed to apply medicated lotion as ordered by the physician. Failed to provide safe transfer techniques and to follow physician orders for assistive transfer equipment for two residents. A licensed nurse instructed one resident to stand in the bathroom for a dressing change. The nurse did not use a gait belt and failed to lock the wheelchair wheels. When the resident attempted to sit back down, the wheelchair rolled back and the resident started to slide to the floor. The nurse and surveyor caught the resident and assisted the resident into the wheelchair. The second resident was totally dependent on staff for transfers and had a physician's order for transfers by a mechanical lift (supports the resident's whole body). When the physician ordered the use of the mechanical lift, nursing staff did not revise the resident's care plan and profile instruction sheet to reflect the change in orders. During an observation, staff transferred the resident using a standup lift (the resident must be able to bear weight) and said they did not know they were supposed to have used the mechanical lift.
Facility: Golden Acres Independence, MO 12-Bed Residential Care Facility Date of Notice: September 2007		Owner: JOACLA Community Services, Inc. Operator: JOACLA Community Services, Inc. Registered Agent: Henry Lara	Legal Action: DENIAL OF LICENSE APPLICATION
Description: “On September 5, 2007. the Department of Health and Senior Services' Section for Long Term Care Regulation (SCLR) received the application of JOACLA Community Services, Inc., for a license to operate Golden Acres, a 12-bed Residential Care Facility in Independence, Missouri. This letter constitutes notice of the Department of Health and Senior Services' decision to deny the application for a license to operate the facility.”
Facility: Lutheran Nursing Home Concordia, MO 120-Bed Skilled Nursing Facility Date of Notice: September 2007		Owner: The Lutheran Nursing Home Operator: Same Registered Agent: Paul Tebbenkamp	Legal Action: Uncorrected Class II Notice of Noncompliance
Description: The facility failed to investigate, notify the physician and the state agency of bruising of unknown origin for one resident. The resident was totally dependent on staff for all care. On 8/10/07, the physician ordered staff to apply a lower extremity abductor roll/wedge to the resident's right lower leg. On 8/30/07, staff identified yellow bruising to the right side of the resident's groin. Staff did not document they notified the physician, did not fill out an incident report or initiate an investigation and did not document any further information about the bruising until 9/3/07. During a bath on 9/3/07, staff identified the resident had yellow bruising in the groin area that extended to the hip and back of the leg. Staff thought the bruising was caused from the abductor roll/wedge and did not fill out an incident report or initiate any further investigation as to the cause of the bruising. An x-ray was not done until 9/7/07. The x-ray showed the resident had no acute bony injury.
Facility: Greens at Creekside Kansas City, MO 180-Bed Skilled Nursing Facility Date of Notice: November 2007		Owner: Chaudhary International, LLC Operator: Fayjay, Inc. Registered Agent: Stephanie G. Hazelton	Legal Action: Uncorrected Class II Notice of Noncompliance
Description: The facility failed to: consistently document the effectiveness of narcotic pain medication for one resident and failed to complete a pain assessment for one resident who had fallen; to follow acceptable infection control procedures and acceptable standards of practice when providing care to one resident with an indwelling catheter who had a urinary tract infection; develop and implement measures to prevent one resident with a history of falling, from further falls and injury.

NORTHEAST REGION
Facility: Bristol Manor of Monroe City Monroe City, MO 12-Bed Residential Care Facility Date of Notice: March 2007	Owner: Bristol Care, Inc. Operator: Bristol Care, Inc. Registered Agent: David C. Furnell		Legal Action: Uncorrected Class II Notice of Noncompliance
Description:  The facility failed to implement an effective system of medication administration. The facility failed to ensure physician's orders were being followed. The facility failed to implement effective procedures to minimize the presence of rodents in the facility. The facility failed to assure that food items were protected from potential contamination by rodents.
Facility: Golden Hour RCF New Franklin, MO            16-Bed Residential Care Facility Date of Notice: April 2007		Owner: Hilderbrand Properties, Inc. Operator: Alvima Enterprises, Inc. Registered Agent: Leigh Hilderbrand	Legal Action: Class I Notice of Noncompliance
Description: The facility failed to ensure hot water temperatures in resident use areas did not exceed 120 degrees Fahrenheit. The facility census was 13 residents.
Facility: Schuyler County Nursing Home Queen City, MO 60-Bed Skilled Nursing Facility Date of Notice: April 2007		Owner: Schuyler Co. Nursing Home Dist. Operator: Same Registered Agent: Not Listed	Legal Action: Uncorrected Class II Notice of Noncompliance
Description: The facility failed to provide necessary treatment and services to promote healing and prevention of pressure sores for one resident. The facility failed to provide battery operated emergency lighting for four of five emergency exit discharges that led to a public way that would supply illumination of the exits in the event of a power failure. The facility does not have a generator.
Facility: Westport Estates Assisted Living by Americare Marshall, MO 40-Bed Residential Care Facility Date of Notice: April 2007		Owner: Marshall Residential, LLC Operator: Same Registered Agent: Husch Registered Agent, Inc.	Legal Action: Uncorrected Class II Notice of Noncompliance
Description: The facility failed to ensure one hazardous area was protected by a self-closing or automatic closing door. The facility failed to maintain sprinkler heads throughout the building free from debris. The facility failed to ensure all wastebaskets in the facility had a fire-resistant rating. The facility failed to ensure the water temperature in resident rooms on the southwest hallway did not exceed one hundred and twenty degrees Fahrenheit (F). The facility failed to ensure poisonous or toxic materials were stored in a locked place that was not accessible to residents.
Facility: Shinn Residential Center Hannibal, MO 9-Bed Residential Care Facility Date of Notice: April 2007		Owner: Shinn Residential Center, Inc. Operator: Same Registered Agent: Gary W. Shinn	Legal Action: Uncorrected Class II Notice of Noncompliance
Description: The facility failed to ensure a safe system of medication use. Of 65 opportunities for error, staff made 14 errors including errors of omission and technique resulting in a 21.5% medication error rate.
Facility: Golden Hour RCF New Franklin, MO 16-Bed Residential Care Facility Date of Notice: May 2007		Owner: Hilderbrand Properties, Inc. Operator: Alvima Enterprises, Inc. Registered Agent: Leigh Hilderbrand	Legal Action: Class I Notice of Noncompliance
Description: On 4/17/07 a licensure inspection was completed. The facility was not in substantial compliance with participation requirements. On 5/03/07 a revisit was completed. The facility was issued a Notice of Noncompliance as a result of the uncorrected deficiency, which present either imminent danger to the health, safety or welfare of any resident. The facility failed to ensure hot water accessible to residents was thermostatically controlled so that the temperature at the faucet did not exceed 120 degrees F (Fahrenheit).
Facility: Golden Hour RCF New Franklin, MO 38-Bed Residential Care Facility Date of Notice: May 2007		Owner: Hilderbrand Properties, Inc. Operator: Alvima Enterprises, Inc. Registered Agent: Leigh Hilderbrand	Legal Action: Class I Notice of Noncompliance
Description: On 4/17/07 the facility was issued a Notice of Noncompliance. On 5/3/07 a revisit was completed. The facility was not in substantial compliance with participation requirements. The facility failed to ensure hot water accessible to residents was thermostatically controlled so that the temperatures at the faucet did not exceed 120 degrees F (Fahrenheit).
Facility: Bristol Manor of Monroe City Monroe City, MO 12-Bed Residential Care Facility Date of Notice: May 2007		Owner: Bristol Care Inc. Operator: Same Registered Agent: David C. Furnell	Legal Action: Uncorrected Class II Notice of Noncompliance
Description: A complaint investigation was completed on 11/27/06. The facility was not in substantial compliance with participation requirements. Revisits were completed on 2/23/07 and 4/30/07. The facility staff failed to provide a safe and effective medication system consistent with acceptable nursing techniques when administering eye drops and inhalers. Also, the facility failed to maintain an environment free of pest and rodents. Facility staff failed to maintain sprinkler heads free of paint and tape to ensure appropriate functioning.
Facility: Mexico Manor, Inc. Mexico, MO 34-Bed Skilled Nursing Facility Date of Notice: May 2007		Owner: Mexico Manor, Inc. Operator: Same Registered Agent: Husch Registered Agent, Inc.	Legal Action: Uncorrected Class II Notice of Noncompliance
Description: The facility failed to: Immediately notify the physician when one resident had a deterioration in condition while on Coumadin (an anticoagulant) in combination with numerous other medications and required hospitalization for gastrointestinal bleeding. The facility also failed to consult the resident's physician when the resident had poor food consumption and significant weight loss. Provide assurance all personal funds of residents who would choose to have the facility hold and manage their funds were secure. Obtain and follow signed physician's orders for medications, diet, and treatments for one resident. Obtain physicians' orders upon admission, failed to monitor resident's blood sugar and fluid intake and output, and failed to keep the resident's attending physician informed of one resident's deterioration in condition. Provide proper incontinence care to keep residents clean and dry. Ensure staff washed their hands after each direct resident contact and during medication administration. Ensure that nurse aides were able to demonstrate competency in skills and techniques necessary to care for the needs of the residents and basic personal care. The facility failed to ensure nurse aides were competent to provide personal hygiene care and hand washing.
Facility: Country View Nursing Facility, Inc. Bowling Green, MO 60-Bed Skilled Nursing Facility Date of Notice: June 2007		Owner: CCC Country View, LLC Operator: Country View Nursing Facility, Inc. Registered Agent: James J. Giardina	Legal Action: Uncorrected Class II Notice of Noncompliance
Description: A complaint investigation was completed on 4/05/07. The facility was not in compliance with participation requirements. A revisit was completed on 5/29/07. The facility staff failed to follow physician orders, provide appropriate incontinent care to resident and change residents positions as directed in the plan of care, provide services to prevent the development or decline of resident's pressure sores and ensure nurse aides were certified or enrolled in a certification course within four (4) months of hire prior to providing resident care on a full time basis. Also, the facility failed to ensure the maintenance, repair and testing of the sprinkler system.
Facility: Westview Nursing Home Center, MO 60-Bed Skilled Nursing Facility Date of Notice: August 2007		Owner: BKY Properties, Inc. Operator: BKY Healthcare of Center, Inc. Registered Agent: William H. Harris	Legal Action: Uncorrected Class II Notice of Noncompliance
Description: On 6/06/07 an abbreviated survey was completed at the facility. The facility was not in substantial compliance with participation requirements. A revisit was completed on 8/13/07. The facility failed to ensure the environment was free of accident hazards and each resident receives adequate supervision and assistance devices to prevent accidents. The facility staff failed to ensure residents' personal safety alarms remained attached and functional, implement ordered safety interventions or to ensure staff were available to intervene when safety devices alarmed, use a gait belt to reposition one resident or use a proper sling size to transfer another resident with the mechanical lift. In addition to the uncorrected deficiency new deficiencies were found in the area of: provide care in a manner to promote residents' dignity; assistance to dependent residents unable to carry out activities of daily living; pressure sore treatment and prevention; ensure adequate staff was available to meet the needs of residents; ensure residents had access to fluids at all times; maintain two of four blood pressure cuffs used to assess residents were appropriately calibrated; ensure residents had a call system accessible for use to communicate with facility staff.
Facility: Country View Nursing Facility, Inc. Bowling Green, MO 60-Bed Skilled Nursing Facility Date of Notice: August 2007		Owner: CCC Country View, LLC Operator: Country View Nursing Facility, Inc. Registered Agent: James J. Giardina	Legal Action: Uncorrected Class II Notice of Noncompliance
Description: The facility failed to provide the necessary services to maintain good personal hygiene for three of four sampled residents (Residents' #1, #9, and #40). The facility staff failed to remove soiled gloves and/or wash their hands while providing personal care for two of four sampled residents (Residents' #1 and #40) as indicated by accepted practice to prevent the spread of infection and/or cross-contamination.
Facility: Crosspointe Residential Care Facility Inc. Edina, MO 47-Bed Residential Care Facility Date of Notice: August 2007		Owner: Not Listed Operator: W.L.E., LLC Registered Agent: Dewayne Wellborn	Legal Action: Uncorrected Class II Notice of Noncompliance
Description: A licensure (sic) was completed on 1/4/07. The facility was not in compliance with participation requirements. A revisit was completed on 5/14/07. The facility was issued a Class I Notice of Noncompliance for failure to ensure the area of the lower level south lounge did not present as a significant fire and safety hazard.  SLCR issued a license revocation letter, effective July 13, 2007. On 7/12/07 SLCR conducted a monitoring visit and found multiple provisions of the AHC stay of licensure action were not met. Additionally, new deficiencies were cited.
Facility: Moberly Nursing and Rehab Moberly, MO 120-Bed Skilled Nursing Facility Date of Notice: September 2007		Owner: Not Listed Operator: N & R of Moberly, Inc. Registered Agent: Charlotte Stutts	Legal Action: Uncorrected Class II Notice of Noncompliance
Description: The facility failed to administer medications with an error rate of less than 5% for three residents. There were 50 opportunities for errors observed, with five medication errors, which resulted in an error rate of 10 percent.
Facility: Silex Community Care Silex, MO 60-Bed Skilled Nursing Facility Date of Notice: September 2007		Owner: Lincoln County Operator: N & R of Silex, Inc. Registered Agent: Charlotte Stutts	Legal Action: Uncorrected Class II Notice of Noncompliance
Description: The facility failed to monitor physician's signed orders for medication changes for two of nine sampled residents (Residents #9 and #15) which included staff continuing to administer medication that had been discontinued and failed to order medication for Resident #9 and staff failed to accurately transcribe physician's orders onto the medication administration record and accurately administer medications prescribed for Resident #15. The facility failed to assess and monitor one resident's skin condition and timely notify the resident's physician (Resident #25) of nine sampled residents. The facility failed to ensure delayed egress locks on two of six designated exit doors remained released upon silencing of the fire alarm system until the system was reset.
Facility: Westview Nursing Home Center, MO 60-Bed Skilled Nursing Facility Date of Notice: October 2007		Owner: BKY Properties, Inc. Operator: BKY Healthcare of Center, Inc. Registered Agent: Brandon York	Legal Action: Uncorrected Class II Notice of Noncompliance
Description: A complaint investigation was completed on 6/06/07. The facility was not in substantial compliance with participation requirements. Revisits were completed on 8/31/07 and 10/03/07 along with the annual survey. It was determined that the facility staff failed to make the following required corrections: - provide care in a manner and environment that maintained or enhanced the dignity of the residents. - ensure that 6 of 10 sampled residents and one expanded sampled resident, who needed extensive or total assistance with grooming and personal hygiene, received assistance based on their individual needs. – serve thickened liquids as ordered by the resident's physician, transferring residents without the use of a gait belt, unsafe placement of gait belt, unsafe transfers, improper placement in Hoyer lift, call lights not accessible, not serving pureed diets and not assessing and monitoring blood glucose levels. – ensure one resident maintained proper hydration. Additional violations in the areas of Administration, Quality of Care and Quality of Life were discovered as a result of the annual survey.
Facility: Golden Livingcenter-Colonial Manor of Albany Albany, MO 60-Bed Skilled Nursing Facility Date of Notice: October 2007		Owner: Not Listed Operator: GGNSC Albany LLC Registered Agent: CSC-Lawyers Incorporating Service	Legal Action: Class I Notice of Noncompliance
Description: A complaint investigation was completed on 10/16/07. The facility was not in substantial compliance with participation requirements. The facility failed to provide adequate oversight to prevent two residents from leaving the facility without staff knowledge. Facility staff had assessed both residents as having cognitive impairment, a lack of safety awareness and being at risk for elopement. Resident #1 was gone from the facility approximately 15 minutes. An off duty facility staff person found the resident approximately three blocks from the facility, where the resident had crossed Highway 136. A pharmacy technician found Resident #2 in the lane between Highway 136, which is a heavily traveled road, and the facility parking lot. The technician took Resident #2 back into the facility.
Facility: Crosspointe RCF Edina, MO 47-Bed Residential Care Facility Date of Notice: November 2007		Owner: Not Listed Operator: W.L.E. LLC Registered Agent: Dewayne Wellborn	Legal Action: Uncorrected Class II Notice of Noncompliance
Description: The administrator failed to properly supervise and oversee the appropriate reimbursement of residents' funds, failed to ensure the facility was in compliance with fire safety requirements, and ongoing issues related to a safe and clean environment. The facility failed to use the personal funds of residents exclusively for the use of the residents and failed to obtain authorization in writing from residents to withdraw funds from the residents' trust fund accounts. The total resident trust funds not accounted for were $7,028.76.
Facility: Milan Health Care Facility Milan, MO 100-Bed Skilled Nursing Facility Date of Notice: November 2007		Owner: Lisa Van Velzer Operator: N & R Milan, Inc. Registered Agent: Charlotte Stutts	Legal Action: Uncorrected Class II Notice of Noncompliance
Description: A survey was completed on 9/13/07. The facility was not in substantial compliance with participation requirements. A revisit was completed on 10/29/07. The facility failed to correct the following violations: The facility staff failed to notify one resident's physician when the resident suffered a fall with injury to his/her head. The resident fell on 10/22/07 striking his/her head against the door. Staff sent a fax to the resident's physician even though staff knew the physician was not in his/her office to receive the faxed information. The facility staff failed to provide adequate supervision and assistive devices for one resident to prevent accidents. Facility staff failed to develop and implement measures to prevent further falls and injuries for one resident who had multiple falls. On 10/22/07 the resident fell striking his/her head against a door. The resident suffered facial bruising and swelling. On 10/29/07 staff transferred the resident to the hospital emergency room for evaluation (seven days after falling) for multiple falls and progressive weakness. The resident was admitted to the hospital with urinary tract infection, dehydration and cellulites of the face.
Facility: North Village Park Moberly, MO 184-Bed Skilled Nursing Facility Date of Notice: November 2007		Owner: M S Associates LP Operator: North Village Park, LC Registered Agent: Joanna W. Owen	Legal Action: Uncorrected Class II Notice of Noncompliance
Description: The facility failed to provide services necessary for one resident to attain the highest practicable physical well being when facility staff failed to obtain a physician's order before treating one resident with a possible spider bite and failed to update the physician on the status of the area. The facility failed to provide adequate supervision and assistance devices to one resident during positioning of the resident on a transfer/lift pad which allowed the resident to fall out of bed and sustain a fractured femur. The facility failed to provide adequate assistance devices to reposition one resident who had a history of a prior fracture. The facility failed to ensure that residents did not receive significant medication errors when staff administered one resident the incorrect type and dose of insulin and the resident required hospitalization for evaluation/treatment.
Facility: Maple Lawn Nursing Home Palmyra, MO 140-Bed Skilled Nursing Facility Date of Notice: December 2007		Owner: Marion Co. Nursing Home Dist. Operator: Same Registered Agent: Not Listed	Legal Action: Class I Notice of Noncompliance
Description: 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. The facility failed to administer pain medication and provide other care and interventions for residents to have comfort and relief from terminal cancer pain, wound pain and other forms of pain. The facility failed to provide consistent monitoring, care and interventions to prevent constipation that lead to bowel impaction and/or bowel obstruction for three residents. The facility failed to provide consistent treatment and nutritional support to promote healing of skin wounds for three residents. The facility failed to keep residents free from avoidable pressure sores, taking measures toward prevention. The facility failed to develop and follow facility policies for the prevention of pressure ulcers and failed to provide treatment of existing pressure ulcers for residents. The facility failed to complete ongoing assessments, failed to develop care plan interventions, failed to notify the physician when facility residents developed pressure ulcers, failed to document treatments to promote healing and failed to provide care as ordered. The facility census was 118 residents.

NORTHWEST REGION
Facility: Golden Livingcenter-Smithville Smithville, MO 120-Bed Skilled Nursing Facility Date of Notice: January 2007	Owner: Not Listed Operator: GGNSC Smithville, LLC Registered Agent: CSC-Lawyers Incorporating Service Company		Legal Action: Uncorrected Class II Notice of Noncompliance
Description: The facility failed to maintain clean facility floors and walls, repair splintered wooden cabinets and a chipped sink in resident rooms. The facility failed to ensure staff followed physician's orders to administer medications and treatments. The facility failed to maintain the exterior premises free of weeds, tall grass and refuse. The facility did not maintain an orderly exterior when they stored building supplies and tools on the exterior grounds. The facility did not maintain the west basement corridor floor and west basement room floor clean and in good repair. The facility failed to conduct checks of the Employee Disqualification List, in accordance with Missouri state law, prior to staff having contact with residents. The facility failed to maintain doors that protected corridor openings to ensure they resisted the passage of smoke and had no impediments to closing. The facility failed to provide safe electrical wiring at wall outlets in a resident room.
Facility: Hillview Nursing & Rehab Platte City, MO 120-Bed Skilled Nursing Facility Date of Notice: February 2007		Owner: Plattecare Inc. Operator: N&R of Platte City, Inc. Registered Agent: Charlotte Stutts	Legal Action: Uncorrected Class II Notice of Noncompliance
Description: The facility failed to assure staff obtained physician ordered laboratory test results in a timely manner, failed to obtain a new urine sample when the lab service was not able to transport the sample in a timely manner, failed to start a physician ordered antibiotic in a timely manner and failed to notify the physician of an elevated temperature.
Facility: Bristol Manor of Maryville Maryville, MO 12-Bed Residential Care Facility Date of Notice: February 2007		Owner: Not Listed Operator: Bristol Care, Inc. Registered Agent: David C. Furnell	Legal Action: Class I Notice of Noncompliance
Description: The facility failed to maintain existing fire safety standards, when the manager failed to assure the facility's designated emergency exits were clear of ice and snow. Two of the three emergency exits discharges were blocked with ice and snow for at least four days. The blocked exits placed seven of the nine residents, on two of two resident wings, at risk from fire or other emergencies that could require the residents to use an exit other than the front door exit.
Facility: Pleasant View Rock Port, MO 60-Bed Skilled Nursing Facility Date of Notice: March 2007		Owner: Pleasant View Estates Operator: Tiffany Care Centers, Inc. Registered Agent: David Duncan	Legal Action: Uncorrected Class II Notice of Noncompliance
Description: The facility failed to assure staff administered insulin in a timely manner in relation to a blood sugar test for one resident. The facility failed to assure staff administered insulin according to the physician's orders for one resident. The facility failed to implement measures to prevent falls for one resident with a history of falls.
Facility: Liberty Terrace Healthcare & Rehabilitation Liberty, MO 143-Bed Skilled Nursing Facility Date of Notice: March 2007		Owner: Liberty Terrace Healthcare & Rehabilitation Operator: Same Registered Agent: National Registered Agents, Inc.	Legal Action: Class II Notice of Noncompliance
Description: The facility failed to provide supervision during meals for one resident who had three prior incidents of choking, two of which required staff to perform the Heimlich maneuver. On 2/12/07, the resident had a fourth episode of choking on meat at the evening meal. Staff performed the Heimlich maneuver. The resident required hospitalization.
Facility: Cameron Manor Cameron, MO 120-Bed Skilled Nursing Facility Date of Notice: April 2007		Owner: MLD Real Estate, Inc. Operator: J&R Associates, LP Registered Agent: Edward C. Clausen	Legal Action: Class I Notice of Noncompliance
Description: The facility failed to ensure staff implemented emergency procedures for one resident, when one licensed staff found the resident without a pulse or respirations and failed to initiate cardiopulmonary resuscitation.
Facility: Royal Care Center, Inc. Excelsior Springs, MO 108-Bed Skilled Nursing Facility Date of Notice: April 2007		Owner: Royal Care Center, Inc. Operator: Same Registered Agent: Jesse J. Hwang	Legal Action: Class I Notice of Noncompliance
Description: The facility failed to investigate allegations of abuse, investigate injuries of unknown origin, and prevent further potential abuse. The facility failed to identify, assess, and implement a plan of care addressing resident's aggressive and abusive behaviors. The facility failed to ensure one resident with impaired cognitive skills from leaving the facility unattended on numerous occasions. The facility failed to ensure one resident received transfer assistance to prevent an accident with injury.
Facility: Hill Crest Manor Hamilton, MO 90-Bed Skilled Nursing Facility Date of Notice: April 2007		Owner: Hamilton Development Properties, LLC Operator: Hamilton #1, Inc. Registered Agent: Not Listed	Legal Action: Class I Notice of Noncompliance
Description: The facility failed to provide protective oversight for one of seven residents who the facility identified at risk for elopement. On 3/31/07, the resident eloped from the facility and the resident's spouse notified the facility the resident was at the resident's former home.
Facility: Liberty Terrace Healthcare & Rehabilitation Liberty, MO 143-Bed Skilled Nursing Facility Date of Notice: April 2007		Owner: Liberty Terrace Healthcare & Rehabilitation Operator: Same Registered Agent: National Registered Agents, Inc.	Legal Action: Class II Notice of Noncompliance
Description: The facility failed to ensure one resident, who the facility admitted with Alzheimer's disease and periods of confusion, did not leave the building unattended. The resident left the facility while it was still dark in the early morning hours. For up to one hour, staff were unaware the resident had left the facility. The facility also failed to follow their policy to assess each resident upon admission and ongoing, to determine if residents were at risk for eloping.
Facility: Indian Hills Nursing Home, Inc. Chillicothe, MO 75-Bed Skilled Nursing Facility Date of Notice: April 2007		Owner: Indian Hills Nursing Home, Inc. Operator: Same Registered Agent: Don Chapman, Jr.	Legal Action: Class I Notice of Noncompliance
Description: Facility staff failed to provide a safe environment, free from accidents, when staff transported one resident by wheelchair without foot pedals. This failure caused the resident to fall from the wheelchair, resulting in two cervical spine fractures. The facility failed to ensure facility transportation staff secured one resident according to manufacturer's directions prior to transporting the resident in a wheelchair in the facility shuttle bus. This failure caused the resident's wheelchair to tip over during transport, resulting in the resident receiving a fractured left clavicle, a cervical spine fracture and a laceration to the back of the head.
Facility: Bristol Manor of Lexington Lexington, MO 12-Bed Residential Care Facility Date of Notice: May 2007		Owner: Bristol Care, Inc. Operator: Same Registered Agent: David C. Furnell	Legal Action: Class I Notice of Noncompliance
Description: The facility failed to ensure one resident (Resident #1), an insulin dependent diabetic, received proper care to meet his/her needs by failing to obtain parameters or instructions regarding blood sugar levels, when to notify the physician of hypoglycemic episodes, clarify orders with the physician, document changes of condition in the nurse's notes, and to adequately monitor the resident's condition. The facility census was six residents.
Facility: Saxton Riverside Care Center St. Joseph, MO 90-Bed Intermediate Care Facility Date of Notice: May 2007		Owner: Saxton's Inc. Operator: Senior Life, Inc. Registered Agent: Glen Muir	Legal Action: Uncorrected Class II Notice of Noncompliance
Description: The facility staff failed to follow physicians' orders and assure Resident #16 received antibiotics ordered for chest congestion and increased temperature. The facility failed to assure licensed staff assessed Resident #16's level of pain and provide pain management from 4/5/07 to 4/17/07. Resident #16 complained of pain in his/her left arm. Direct care staff documented and reported complaints of pain and bruising of the left arm to the licensed nursing staff. Resident #16's x-ray reports dated 4/17/07 and 4/20/07 showed the resident had a displaced fracture of the left upper arm, a suspect fracture of the right and left lower legs at the knee area.
Facility: Pine View Manor, Inc. Stanberry, MO 70-Bed Skilled Nursing Facility Date of Notice: June 2007		Owner: Pine View Manor, Inc. Operator: Same Registered Agent: Karl Frederick	Legal Action: Class I Notice of Noncompliance
Description: The facility failed to adequately monitor and put in place interventions to keep one of three residents, whom the facility identified was at risk for elopement, from leaving the building unattended. The resident walked to the baseball field (approximately 0.2 of a mile). The facility did not know the resident was gone until after a family member brought the resident back to the facility. The facility did not use a systematic approach to monitor the resident or document how often the staff monitored the resident after the family returned the resident from the ball field.
Facility: Cameron Nursing and Rehabilitation Center Cameron, MO 120-Bed Skilled Nursing Facility Date of Notice: June 2007		Owner: Unlisted Operator: J&R Associates, L.P. Registered Agent: Edward C. Clausen	Legal Action: Class I Notice of Noncompliance
Description: The facility failed to sufficiently monitor the whereabouts of a resident who eloped from the facility. Facility staff did not know the resident was out of the facility until an unidentified woman came into the facility and told staff the resident was outside walking on the road.
Facility: Valley Manor and Rehabilitation Center Excelsior Springs, MO 120-Bed Skilled Nursing Facility Date of Notice: July 2007		Owner: Unknown Operator: Excelsior Springs #1 Inc. Registered Agent: Not Listed	Legal Action: Uncorrected Class II Notice of Noncompliance
Description: A survey was completed on 5/23/07. The facility was not in substantial compliance with participation requirements. A revisit was completed on 7/19/07. The facility staff failed to: ensure floor tiles, shower room wall tiles, window screens and wood veneer on the nurses desk was clean and in good condition; clean one resident's wheelchair arm which was torn revealing the underneath fabric and failed to clean one dependent resident's geri chair that was covered in food debri (sic); follow physician orders for two residents, who required the use of hand splints; provide nail care for three residents who were dependent on staff for assistance and failed to ensure resident's facial hair was removed; ensure foley cather (sic) bags hung below the level of the bladder for two residents and secure the urinary catheter tubing with a leg strap to reduce friction and movement at the insertion site for one resident; keep the stainless steel work table and the surface of the cook stoves clean from a buildup of grease or debri (sic) and ensure the floor between the water line and freezer was clean.
Facility: Superior Park Assisted Living Excelsior Springs, MO 66-Bed Residential Care Facility Date of Notice: July 2007		Owner: DST, Inc. Operator: Same Registered Agent: Thomas A. Walker	Legal Action: Uncorrected Class II Notice of Noncompliance
Description: The facility failed to ensure all bathrooms had a night light.
Facility: Royal Care Center, Inc. Excelsior Springs, MO 108-Bed Skilled Nursing Facility Date of Notice: July 2007		Owner: Royal Care Center, Inc. Operator: Same Registered Agent: Jesse J. Hwang	Legal Action: Uncorrected Class II Notice of Noncompliance
Description: The facility failed to follow their investigation policy to notify the state agency after one staff threatened a resident. The facility failed to ensure staff followed physician's orders and/or acceptable standard of practice for three residents (abnormal urinalysis, urinary tract infection, and discontinue of a medication).
Facility: Indian Hills Nursing Home, Inc. Chillicothe, MO 75-Bed Skilled Nursing Facility Date of Notice: August 2007		Owner: Not Listed Operator: Indian Hills Nursing Home, Inc. Registered Agent: Don Chapman, Jr.	Legal Action: Uncorrected Class II Notice of Noncompliance
Description: The facility failed to assure facility staff transcribed physician's orders to the medication administration record correctly. The facility failed to assure staff followed up with results of a physician's order for a repeat chest x-ray. The facility failed to assure facility staff provided thorough perineal care. The facility failed to assure three residents maintained acceptable parameters of nutritional status. They were not reassessed and interventions put into place when they had significant weight loss.
Facility: Bristol Manor of Bethany Bethany, MO 12-Bed Residential Care Facility Date of Notice: August 2007		Owner: Bristol Care, Inc. Operator: Same Registered Agent: David C. Furnell	Legal Action: Class II Notice of Noncompliance
Description: A complaint investigation was completed on 8/29/07. The facility was not in substantial compliance with participation requirements. The facility failed to ensure one resident, with a history of drug overdose and drug abuse, received the medical attention required when he/she showed signs of drug overdose on August 20, 2007. The facility did not call the doctor, call the ambulance, or check any vital signs except the blood pressure once, and did not hold the resident's scheduled narcotic medications. The ambulance personnel had to administer Narcan to the resident prior to leaving the facility en route to the hospital.
Facility: Saxton Care Chateau St. Joseph, MO 69-Bed Intermediate Care Facility Date of Notice: August 2007		Owner: Saxton Care Chateau, Inc. Operator: Chateau Place, Inc. Registered Agent: Glen Muir	Legal Action: Uncorrected Class II Notice of Noncompliance
Description: The facility staff failed to accurately assess and follow physician's orders to effectively manage pain for one of six sampled residents (Resident #1), who was one of 16 residents facility staff identified with pain issues.
Facility: Sunnyview Nursing Home & Apartments Trenton, MO 154-Bed Skilled Nursing Facility Date of Notice: August 2007		Owner: Grundy County Nursing Home District Operator: Same Registered Agent: Not Listed	Legal Action: Class I Notice of Noncompliance
Description:  The facility failed to provide proper protective oversight and supervision to one of five sampled residents (Resident #1) who was given a regular diet in place of his/her physician-ordered pureed diet, which caused the newly-admitted resident to choke on the regular food and become unconscious. The facility staff also failed to immediately initiate cardiopulmonary resuscitation (CPR) when the resident choked on the regular food and became unconscious. The resident died at a local hospital.
Facility: Royal Care Center, Inc. Excelsior Springs, MO 108-Bed Skilled Nursing Facility Date of Notice: September 2007		Owner: Not Listed Operator: Royal Care Center Registered Agent: Jesse J. Hwang	Legal Action: Class I Notice of Noncompliance
Description: The facility failed to monitor one resident that staff identified with confusion and at risk for elopement to ensure the resident did not leave the facility unattended. The resident left the facility without staff's knowledge and a neighbor found the resident near a heavily traveled highway. Staff also failed to apply a hot pack treatment according to acceptable practice, physician's orders, and the facility's written protocol, resulting in a second-degree burn for one resident.
Facility: Golden Livingcenter-Colonial Manor of Albany Albany, MO 64402 60-Bed Skilled Nursing Facility Date of Notice: October 2007		Owner: Not Listed Operator: GGNSC Albany LLC Registered Agent: CSC-Lawyers Incorporating Service	Legal Action: Class II Notice of Noncompliance
Description: A complaint investigation was completed on 10/16/07. The facility was not in substantial compliance with participation requirements. The facility failed to provide adequate oversight to prevent two residents from leaving the facility without staff knowledge. Facility staff had assessed both residents as having cognitive impairment, a lack of safety awareness and being at risk for elopement. Resident #1 was gone from the facility approximately 15 minutes. An off duty facility staff person found the resident approximately three blocks from the facility, where the resident had crossed Highway 136. A pharmacy technician found Resident #2 in the lane between Highway 136, which is a heavily traveled road, and the facility parking lot. The technician took Resident #2 back into the facility.
Facility: Lake Viking Health Care Gallatin, MO 97-Bed Skilled Nursing Facility Date of Notice: November 2007		Owner: Daviess County Operator: N & R Gallatin, Inc. Registered Agent: Charlotte Stutts	Legal Action: Uncorrected Class II Notice of Noncompliance
Description: The facility failed to prevent and promote healing of pressure sores for two residents (Residents' #14 and #15). The facility failed to update care plans for one sampled resident (Resident #8) and one additional resident (Resident #14).
Facility: Saxton Care Chateau St. Joseph, MO 69-Bed Intermediate Care Facility Date of Notice: November 2007		Owner: Saxton Care Chateau, Inc. Operator: Chateau Place, Inc. Registered Agent: Glen Muir	Legal Action: Uncorrected Class II Notice of Noncompliance
Description: At the revisit, the facility failed to: Perform physician ordered intermittent urinary catheterization and failed to notify the physician when the resident refused the procedure. The resident had an enlarged prostate and had urinary retention. Thoroughly assess risk factors, failed to develop a plan of care and interventions for one resident identified with a history of falls and at high risk for further falls. To assure a medication error rate of less than five percent. At the revisit, staff did not administer medications as ordered that resulted in a 10.2% error rate.
Facility: Liberty Terrace Healthcare and Rehab Center Liberty, MO 143-Bed Skilled Nursing Facility Date of Notice: December 2007		Owner: Liberty Terrace Healthcare and Rehabilitation Center, LLC Operator: Same Registered Agent: National Registered Agents, Inc.	Legal Action: Class II Notice of Noncompliance
Description: The facility failed to provide adequate supervision, care, interventions, and assistance devices to prevent an accident or injury for one resident (Resident #1) of 14 sampled residents whom staff identified as using one-quarter length side rails and a low air-loss mattress (a specialty mattress). The facility failed to accurately assess and develop interventions to address the resident's use and risk associated with the low air-loss mattress and side rails. The facility did not obtain a physician's order for the resident's use of the one-quarter length side rails; did not provide monitoring of the low air-loss mattress and the resident's positioning on the low air-loss mattress; did not provide settings of the low air-loss mattress in the resident's care plan; and did not provide training and documentation for staff on the mechanics of the low air-loss mattress and how to use them according to the manufacturer's recommendations and facility policy.  On 11/26/07 at approximately 6:00 a.m., facility staff found the resident between his/her low air-loss mattress and the one-quarter-length side rail. The resident's buttocks were on the floor, his/her left leg was under his/her right thigh, and the side rail was across the left side of his/her upper chest just below his/her windpipe. On 11/26/07 at 7:20 a.m., the coroner pronounced the resident deceased.
Facility: Golden Livingcenter – Smithville Smithville, MO 120-Bed Skilled Nursing Facility Date of Notice: December 2007		Owner: Not Listed Operator: GGNSC Smithville, LLC Registered Agent: CSC – Lawyers Incorporating Service	Legal Action: Uncorrected Class II Notice of Noncompliance
Description: The facility failed to assure staff followed physician's orders when providing wound/skin care for five residents.
Facility: Sunset Home Maysville, MO 60-Bed Skilled Nursing Facility Date of Notice: December 2007		Owner: DeKalb County Commission Operator: N & R of Maysville, LLC Registered Agent: Charlotte Stutts	Legal Action: Uncorrected Class II Notice of Noncompliance
Description: The facility failed to clarify physician's orders for oxygen administration. The facility failed to ensure staff transferred one resident in a safe manner.

SOUTHEAST REGION
Facility: St. Francois Manor, Inc. Farmington, MO 118-Bed Skilled Nursing Facility Date of Notice: January 2007	Owner: St. Francois Place, LLC Operator: St. Francois Manor, Inc. Registered Agent: Sharo Shirshekan	Legal Action: Class I Notice of Noncompliance
Description: The facility failed to provide protective oversight and failed to provide sufficient numbers and sufficiently qualified nursing personnel to prevent one resident from eloping from the facility.  The facility failed to ensure one resident (Resident #1) received adequate supervision by sufficient numbers of qualified staff to prevent elopement, failed to ensure staff knew the codes to all keypads in the locked units, failed to ensure all the keypads were functioning and failed to take measures to ensure residents did not know the codes to the keypads. The facility identified that Resident #1 had a history of elopement. Resident #1 resided on the locked 400 hall. The facility assigned one staff person to cover both the 400 and 500 halls on the night shift of 12/16/06. Twelve residents resided on the locked 400 hall and nine residents resided on the locked 500 hall. Resident #1 knew the code to the keypad to go outside into the courtyard. PT A did not know the code to go outside and return the resident to the facility. While PT A went to another part of the facility to find out what the keypad code was, Resident #1 climbed over the courtyard fence and hitchhiked to a family member's home in St. Louis. In addition, the keypad on the outside of the 400 hall did not function and neither residents nor staff would have been able to reenter the facility through that door.
Facility: Chaffee Nursing Center Chaffee, MO 71-Bed Skilled Nursing Facility Date of Notice: March 2007	Owner: Chaffee Nursing, LLC Operator: Same Registered Agent: Husch Registered Agent, Inc.	Legal Action: Class I Notice of Noncompliance
Description: The facility failed to: assure one resident was free of verbal, physical and mental abuse by a staff person; to thoroughly investigate the allegations of abuse; to prevent the potential for further abuse of this resident and other residents, as the facility allowed the staff person to care for residents from 1/22-3/2/07 after the administrator and Director of Nurses became aware of the allegations; to report the allegations of abuse to the state survey and certification agency that abuse had occurred.
Facility: Caruthersville Nursing Center Caruthersville, MO 94-Bed Skilled Nursing Facility Date of Notice: March 2007	Owner: Pemiscot County Memorial Hospital Operator: Same Registered Agent: Not Listed	Legal Action: Class I Notice of Noncompliance
Description: The facility failed to ensure staff used proper technique when repositioning residents in bed. This practice resulted in an injury, which required emergency medical treatment for one resident.
Facility: Country View Residential Care Gideon, MO 12-Bed Residential Care Facility Date of Notice: June 2007	Owner: Randolph, Carroll & Karen Operator: Carroll Randolph Registered Agent: Not Listed	Legal Action: Class I Notice of Noncompliance
Description:  The facility failed to provide twenty-four (24) hour protective oversight for four residents (Resident #1, #2, #3, and #4), when the manager left the facility to take a resident to a doctor's appointment and left residents unattended in the facility and gave a resident (Resident #1) instruction to give the other residents left in the facility noon medications she had set up prior to leaving the facility. The facility also failed to ensure a safe method of medication control and use and failed to ensure that individuals are certified to administer medications. This effected (sic) Residents #1, #2, and #3 with the potential to affect all the residents. The facility also failed to document medications administered in the Medication Administration Record (MAR) for eight of eight (Resident #1, #2, #3, #4, #5, #6, #7, and #8) residents.
Facility: Clearview Nursing Center Sikeston, MO 98-Bed Skilled Nursing Facility Date of Notice: September 2007	Owner: SEMO Care Centers, Inc. Operator: N & R Sikeston at Clearview, Inc. Registered Agent: Charlotte Stutts	Legal Action: Uncorrected Class II Notice of Noncompliance
Description: On July 17, 2007, a survey was conducted at this facility. A revisit was conducted on September 13, 2007. During the revisit, the facility was found to have uncorrected deficiencies in the areas of Administration and Resident Care, Dietary Requirements, and Sanitation Requirements for Food Service.
Facility: Essex Residential Care Essex, MO 50-Bed Assisted Living Facility Date of Notice: December 2007	Owner: Theodore A. Elliott Operator: Same Registered Agent: Not Listed	Legal Action: Class I Notice of Noncompliance
Description: The facility failed to ensure there was a working fire alarm system and a fault with part of the fire alarm system was corrected immediately upon discovery. On 11/27/07 a resident activated the fire alarm by pulling the pull station in the dining room. On 11/29/07, the fire alarm panel showed the trouble light was illuminated but had been silenced. The fire alarm panel and the pull station were not reset until 11/29/07. When tested, the fire alarm panel showed “System Normal” and the alarm sounded when tested. The facility census was 48 residents.
Facility: Country Gardens Cape Girardeau, MO 56-Bed Assisted Living Facility Date of Notice: December 2007	Owner: Sample, Johnnie & Tomi Operator: Country Gardens, Inc. Registered Agent: Tomi Sample	Legal Action: Class II Notice of Noncompliance
Description: The facility staff failed to provide adequate oversight and supervision of one resident with a history of elopement and arson from leaving the facility without the guardian's approval. Resident #1 left the facility on two separate occasions; the first time the resident left he/she was gone an hour and the second resident was gone overnight. In addition, the facility failed to develop and implement interventions to monitor the resident after the facility had a fire, even though staff suspected the resident started the fire.

SOUTHWEST REGION
Facility: Tablerock Healthcare Kimberling City, MO 120-Bed Skilled Nursing Facility Date of Notice: January 2007	Owner: Al Schluter Operator: Kindred Nursing Centers East, LLC Registered Agent: CT Corporation System	Legal Action: Class I Notice of Noncompliance
Description: The facility failed to provide for the safety of the residents when heating the dining room with a wood-burning fireplace and failed to adequately monitor the fire for the safety of the residents in a facility with a census of 90.
Facility: Peaceful Pines Poplar Bluff, MO 12-Bed Residential Care Facility Date of Notice: January 2007	Owner: Dugas, Larry & Judy Operator: Peaceful Pines Residential Care Facility, Inc. Registered Agent: Amy Whetsell	Legal Action: Class I Notice of Noncompliance
Description:  The facility failed to provide protective oversight to all 12 residents. The owner/manager employed one resident as the facility van driver to take residents to physician appointments and outings. The owner/manager designated another resident as the voluntary relief driver. The owner/manager also paid for one resident to go to Level I Medication Aide training. Upon completion of the training, the owner/manager employed that resident as the night manager. The owner/manager gave the resident keys to the medication room so the resident could administer medications to the other residents. When working as the night manager, that resident also stole a narcotic medication to administer to himself/herself and required hospitalization for treatment of a drug overdose.
Facility: Oak Brook Residence Springfield, MO 21-Bed Residential Care Facility Date of Notice: February 2007	Owner: Oak Brook Residence, Inc. Operator: Barefoot Boy, LLC Registered Agent: Tammy L. Echessa	Legal Action: Class I Notice of Noncompliance
Description: From 1/13/07 to 2/1/07, five residents of Victorian Manor and 12 residents of Oak Brook Residence were temporarily living at The Oaks, an unlicensed independent living facility. The facility failed to provide protective oversight to the residents while at The Oaks. On 1/31/07, the surveyor became aware that one resident could not be located. Staff at The Oaks did not know how long the resident had been gone and without medication to treat a psychiatric illness. The facility failed to develop and implement a safe and effective system of medication control. On 1/31/07, staff of The Oaks said residents' narcotics and anti-anxiety medications were not available to administer to the residents. On 2/1/07, when the 15 residents were transferred to Oak Brook Residence, staff said they did not have a key to the narcotics box kept in the medication cart and didn't know what to do. In addition, the medication cassettes were completely missing and not available for staff to give to the residents. The amount of each medication missing could not be determined. There was no prior inventory available for review. When arrangements were made with the pharmacy and medication was delivered to the facility, the staff did not know what to do with the medication. Staff said they had received no training in how to check to see if the pharmacy had delivered the medications the residents needed.
Facility: The Neighborhoods at Quail Creek Springfield, MO 102-Bed Skilled Nursing Facility Date of Notice: March 2007	Owner: R H Montgomery Properties, Inc. Operator: Same Registered Agent: Richard H. Montgomery	Legal Action: Class II Notice of Noncompliance
Description:  Based on observation, interview and record review, the facility failed to provide appropriate care to one resident (Resident #1) after a certified medication technician gave the resident a lethal dose of a narcotic pain medication on 1/14/07 that was ordered for another resident. Facility staff failed to carry out and document physician's orders for vital signs, notifying physician of decreased respirations and lethargy, and holding Resident #1's routine medications. Based on observation, interview and record review, facility staff failed to ensure staff identified and administered medication to the proper resident (Resident #1) that resulted in significant medication errors. On 1/14/07, a certified medication technician administered eight medications (including the narcotic pain medication Oxycontin) to Resident #1 that was ordered for another resident. On 1/17/07 the resident died. The coroner said Resident #1 received a lethal dose of Oxycontin on 1/14/07. The facility census was 65 residents.
Facility: Springhill Assisted Living by Americare Neosho, MO 42-Bed Residential Care Facility Date of Notice: March 2007	Owner: Not Listed Operator: Neosho Residential LLC Registered Agent: Husch Registered Agent, Inc.	Legal Action: Class I Notice of Noncompliance
Description: Based on observation, interview, and record review, the facility failed to ensure hot water temperatures were within the required range in resident rooms and resident-use common areas. Seventeen (17) of eighteen (18) residents were ambulatory and could access the hot water independent of staff. The facility census was 18.
Facility: El Dorado Rest Haven El Dorado Springs, MO 60-Bed Residential Care Facility Date of Notice: April 2007	Owner: Curry, Nadine Operator: El Dorado Rest Haven, Inc. Registered Agent: James L. Curry	Legal Action: Class I Notice of Noncompliance
Description: Based on observation and interviews the facility failed to ensure the following requirements were met: Water temperatures exceeded 140 degrees. Fire Safety requirements. Administration and Resident Care requirements. Sanitation Requirements for Food Service. Statutory Requirements for Criminal Background and Employee Disqualification List checks.
Facility: Golden Estate Residential Care Springfield, MO 31-Bed Residential Care Facility Date of Notice: April 2007	Owner: Xia and Mary Residential Care, Inc. Operator: Same Registered Agent: Xia Xiong	Legal Action: Class I Notice of Noncompliance
Description: Based on observation, interview, and record review, the facility failed to ensure hot water temperatures in resident use areas and individual rooms did not exceed 120 degrees. Water temperatures in resident use areas were from 134.3 degrees to 150.2 degrees. All 27 residents in the facility were ambulatory and could access the hot water independent of staff. The facility census was 27.
Facility: Greene Haven Springfield, MO 120-Bed Skilled Nursing Facility Date of Notice: May 2007	Owner: Greene County, Missouri Operator: Greene County Nursing & Care Center, Inc. Registered Agent: Anthoney R. Kriner	Legal Action: Class I Notice of Noncompliance
Description: Based on observation, interview and record review, the facility staff failed to: Protect one resident (Resident #23) from mental and emotional abuse by a staff member (CMT D), failed to protect one resident (Resident #20) from verbal and physical abuse by one resident (Resident #21) and failed to protect one resident (Resident #32) from verbal and physical abuse by one resident (Resident #2). Implement procedures to prohibit abuse when one resident (Resident #2) repeatedly physically and verbally abused another resident (Resident #32) and failed to prohibit abuse by one resident (Resident #21) from physically abusing another resident (Resident #20). Monitor, assess and provide appropriate interventions for one resident (Resident #12) for an acute change in medical condition, resulting in death, which was associated with severe pain, a decline in strength and a fall. The facility failed to provide care and services needed when one resident (Resident #5) required hemodialysis services. The facility failed to assess, monitor, and provide appropriate interventions for two residents (Resident #10 and #18) for an acute decline in medical condition resulting in their deaths. The facility failed to assess, monitor, and provide appropriate interventions for one resident (Resident #24) for an acute decline in medical condition resulting in acute renal failure secondary to profound dehydration and diagnosis of urosepsis. Provide protective oversight for one resident (Resident #16) restrained in a wheelchair with a non-self-releasing seat belt. The resident had cigarettes and a lighter, and smoked unsupervised, outside the facility. The facility also failed to provide appropriate assesssments, interventions for assistive devices to prevent falls, and failed to provide appropriate follow-up assessments after falls for seven residents (Residents #5, #9, #12, #14, #15, #18, #22 and #28).
Facility: Countryside Home Lebanon, MO 20-Bed Residential Care Facility Date of Notice: May 2007	Owner: Theodore & Velma Maydew Revocable Operator: Maydew Velma J. Registered Agent: None	Legal Action: Uncorrected Class II Notice of Noncompliance
Description: Based on observation, record review, and interview, the facility staff failed to ensure the hot water in all resident use bathrooms was below 120 degrees Fahrenheit. This deficiency was originally cited on 1/26/07 and remains uncorrected. Facility census was 16.
Facility: Country Meadow Retirement Home Niangua, MO 10-Bed Residential Care Facility Date of Notice: May 2007	Owner: Woodworth, Minnie C. Operator: Same Registered Agent: Not Listed	Legal Action: Uncorrected Class II Notice of Noncompliance
Description: The facility failed to ensure no section of the building was a fire hazard when it allowed construction of new non-fire resistant walls in the former group living area. The facility also failed to keep the temperature of hot water at or below 120 degrees Fahrenheit (F) in two resident bathrooms. The facility census was 10.
Facility: Bristol Manor of Republic Republic, MO 12-Bed Residential Care Facility Date of Notice: June 2007	Owner: Bristol Care, Inc. Operator: Same Registered Agent: David C. Furnell	Legal Action: Uncorrected Class II Notice of Noncompliance
Description: The facility failed to administer and instruct two residents (Residents #3 and #4) in the proper administration of respiratory inhalers and failed to observe one resident (Resident #2) take his/her medication.
Facility: Royal Care Center, Inc. Excelsior Springs, MO 108-Bed Skilled Nursing Facility Date of Notice: June 2007	Owner: Royal Care Center, Inc. Operator: Same Registered Agent: Jesse J. Hwang	Legal Action: Class I Notice of Noncompliance
Description: The facility failed to assure staff received training according to the manufacturer's specifications when staff incorrectly strapped one resident in his/her wheelchair in the facility van. The facility van struck a curb throwing the resident out of his/her wheelchair. The resident sustained a broken clavicle and lacerations.
Facility: Marshfield Place Marshfield, MO 40-Bed Residential Care Facility Date of Notice: June 2007	Owner: Deaconess Long Term Care of Ohio, Inc. Operator: Same Registered Agent: CT Corporation	Legal Action: Class I Notice of Noncompliance
Description: The facility failed to ensure the hot water temperatures in all resident use areas did not exceed 120 degrees Fahrenheit (F).
Facility: El Dorado Rest Haven El Dorado Springs, MO 60-Bed Residential Care Facility Date of Notice: June 2007	Owner: Curry, Nadine Operator: El Dorado Rest Haven, Inc. Registered Agent: James L. Curry	Legal Action: Uncorrected Class II Notice of Noncompliance
Description: The facility failed to maintain a safe and effective medication system by allowing staff to administer medication they had not poured and prepared. The facility also failed to request a criminal background check and a check of the employee disqualification list of all employees. Facility census was 29.
Facility: Lake's Residential Care I Houston, MO 12-Bed Residential Care Facility Date of Notice: June 2007	Owner: Lake, Aloysius & Irma Operator: Aloysius Lake Registered Agent: Not Listed	Legal Action: Class I Notice of Noncompliance
Description: The facility failed to maintain hot water temperatures in resident accessible areas in a range between 105 and 120 degrees Fahrenheit. Hot water temperatures were: One resident bathroom had 131 degree Fahrenheit hot water at the lavatory. A second resident bathroom had 132.7 degree Fahrenheit hot water at the lavatory. The kitchen sink, accessible to residents, had 133.5 degree Fahrenheit hot water.
Facility: Golden Living Center – Branson Branson, MO 100-Bed Skilled Nursing Facility Date of Notice: September 2007	Owner: Not Listed Operator: GGNSC Branson, LLC Registered Agent: CSC – Lawyers Incorporating Service Company	Legal Action: Class II Notice of Noncompliance
Description: Based on observation, interview, and record review, the facility staff failed to implement preventive measures such as turning, repositioning, and pressure relief for six residents (Residents #2, #8, #9, #10, #12 and #17) at risk for pressure sore development and/or failed to provide necessary care in a manner to prevent and/or treat pressure sores for three residents (Residents #3, #4 and #6) that currently had pressure sores in a sample of 11 residents. The facility census was 43.
Facility: Golden Living Center – Branson Branson, MO 100-Bed Skilled Nursing Facility Date of Notice: September 2007	Owner: Not Listed Operator: GGNSC Branson, LLC Registered Agent: CSC – Lawyers Incorporating Service Company	Legal Action: Class II Notice of Noncompliance
Description: The facility failed to provide the necessary care and services for three of five sampled residents (Residents #1, #2 and #7) to attain their highest practicable physical well-being by failure to provide hemoglobin (oxygen-carrying protein within the red blood cells) monitoring and medication administration for Resident #1, failure to administer an intravenous antibiotic ordered when Resident #2 was re-admitted to the facility from the hospital for treatment of pneumonia, and failure to consistently assess and monitor Resident #7's respiratory status and decline in condition which resulted in a transfer to the hospital.
Facility: Country Acres Residential Care, Inc. Webb City, MO 12-Bed Residential Care Facility Date of Notice: September 2007	Owner: Not Listed Operator: Country Acres Residential Care, Inc. Registered Agent: Karen S. Sisco	Legal Action: Class I and Uncorrected Class II Notice of Noncompliance
Description: A licensure inspection was completed on 6/26/07. The facility was not in substantial compliance with participation requirements. A revisit and complaint investigation was completed on 9/14/07. The facility failed to: provide adequate protective oversight by ensuring a staff person was awake while on duty to provide oversight to the residents; failed to provide proper care to meet the needs of a resident and follow physician orders to discharge the resident to a higher level of care to ensure proper management of the resident's diabetes; failed to ensure staff did not knowingly omit any duties when staff failed to report allegations of sexual misconduct, verbal abuse of residents, ensure medications were in a secured location and not accessible to residents, keeping a resident whose needs could not be met by facility staff, provide adequate oversight and supervision by having an awake staff on duty; failed to ensure residents were not subjected to verbal abuse, threats of retaliation and report to the state agency any suspected abuse of residents; ensure a staff and effective medication system by ensuring medications were properly stored and not accessible by any person other than staff.
Facility: Countryside Home Lebanon, MO 20-Bed Residential Care Facility Date of Notice: September 2007	Owner: Theodore & Velma Maydew Revocable Operator: Maydew, Velma J. Registered Agent: None	Legal Action: TEMPORARY OPERATING PERMIT, TO FACILITY RELOCATION OF RESIDENTS. EXPIRES 10/15/07.
Description: (From letter sent to facility September 7, 2007) “The facility and operator are not in substantial compliance with Class II standards as established pursuant to Section 198.085, RSMo, as exhibited by the Class II violations which are listed in the enclosed Statement of Deficiencies. See Section 198.022.1(2), RSMo Supp. 2006, and the facility has a history of chronic noncompliance with SLCR standards between January 24, 2007 and present as identified in the Statements of Deficiencies previously provided to the facility and the Statement of Deficiencies enclosed in this letter. The facts, upon which the decision is based, are as follows: The facility is not in substantial compliance with Class II standards as described in the enclosed Statement of Deficiencies, and the facts contained in Statements of Deficiencies dated 1/24/07, 4/23/07 and 5/17/07, which have been previously provided to the facility, and the facts in the enclosed Statement of Deficiencies document the facility's history of noncompliance with SLCR standards. On 8/28/2007, the SLCR issued TOP (Temporary Operating Permit) #034735 to your facility with an expiration date of 09/30/2007. A replacement TOP is enclosed for the purpose of facilitating the orderly relocation of residents from the facility. This TOP will expire on 10/15/07. If you continue to care for more than two (2) residents after the TOP becomes null and void, you will be operating without a state license at that time, in violation of Sections 198.015.1, RSMo Supp. 2006 and 198.061.1 RSMo, and the SLCR may request your criminal prosecution or may take any other action authorized by law.”
Facility: Marshfield Place Marshfield, MO 40-Bed Residential Care Facility Date of Notice: September 2007	Owner: Not Listed Operator: Deaconess Long Term Care of Ohio, Inc. Registered Agent: CT Corporation	Legal Action: Uncorrected Class II Notice of Noncompliance
Description: An annual licensure inspection was conducted at the facility on 06/05/07. On 08/29/2007, a revisit was completed and the uncorrected Class II was as follows. The facility failed to develop a safe and effective medication system for properly storing and administering multi-dose vials of solution used for tuberculin testing when staff used outdated solution to test one resident (Resident #1).
Facility: The Neighborhoods at Quail Creek Springfield, MO 102-Bed Skilled Nursing Facility Date of Notice: October 2007	Owner: RH Montgomery Properties, Inc. Operator: RH Montgomery Properties Registered Agent: Richard H. Montgomery	Legal Action: Class II Notice of Noncompliance
Description: Based on observation, interview and record review, the facility failed to obtain a new CAM boot (air cast splint) after becoming aware the boot was rubbing one resident's (Resident #1) foot and the resident acquired a pressure sore to the left Achilles heel in April 2007 from the ill-fitting CAM boot. The facility was aware the boot did not fit properly, that it was rubbing the resident's skin, but did not get a different boot, or notify the orthopedic physician of the ill-fitting CAM boot prior to the development of the pressure sore. The pressure sore resulted in pain to the resident at an 8-9 level on a scale of 10 with an x-ray on 9/7/07, showing suspicious for osteomyelitis.
Facility: Seneca Home Place Seneca, MO 30-Bed Residential Care Facility Date of Notice: October 2007	Owner: Seneca Residential LLC Operator: Community Residence, Inc. Registered Agent: James J. Giardina	Legal Action: Uncorrected Class II Notice of Noncompliance
Description: The facility failed to ensure safe administration of medications. Staff administered outdated insulin to one diabetic resident and administered outdated TB testing solution to another. The facility census was 20.
Facility: Bristol Manor of Aurora Aurora, MO 12-Bed Residential Care Facility Date of Notice: October 2007	Owner: Furnell, David & Lynn Operator: Bristol Care, Inc. Registered Agent: David C. Furnell	Legal Action: Uncorrected Class II Notice of Noncompliance
Description: The facility failed to ensure all staff that check resident's blood sugars or administer insulin is insulin-certified and the facility failed to ensure correct insulin dosages were administered to diabetic residents, which resulted in insulin medication errors for two of two diabetic residents (Resident #1 and #2). The facility also failed to ensure staff did not use outdated insulin.
Facility: Maranatha Vilage, Inc. Springfield, MO 240-Bed Skilled Nursing Facility Date of Notice: November 2007	Owner: General Council Assemblies of God Operator: Maranatha Village, Inc. Registered Agent: Not Listed	Legal Action: Class I Notice of Noncompliance
Description: The facility failed to appropriately assess and provide medication as ordered by the physician for one resident's signs and symptoms of pain. Resident #1 was a hospice patient, was cognitively impaired, had a pressure ulcer on his/her coccyx and exhibited verbal and nonverbal signs of pain. The physician had ordered narcotic pain medication on an as needed basis for pain control. During the survey, surveyors observed the resident to cry, moan, grimace, and rub different body areas during care and during pressure ulcer treatment. Review of Resident #1's October 2007 medication administration revealed staff did not provide the resident with any as needed pain medication for the month of October until 10/24/07 when prompted by the surveyor. The MAR also showed nursing staff did not administer the resident any as need (sic) pain medication on 10/25/07 prior to or during the pressure ulcer treatment.
Facility: Dove Senior Citizen Home Lebanon, MO 30-Bed Residential Care Facility Date of Notice: November 2007	Owner: Price, Dennis & Karen Operator: KRN-DNS, Inc. Registered Agent: Michael P. Dorf	Legal Action: Class I Notice of Noncompliance
Description: Based on record review, observation and interviews, the facility failed to ensure that the building did not present a fire hazard. The facility is a single level wooden frame building without a sprinkler system. The facility had candles, flammable straw decorations and other combustible materials on the interior doors and scattered throughout the facility's three sitting rooms and hallways. Observation revealed a lighter sitting on top of an entertainment center that was accessible to all residents. During observations, one resident had the lighter, flicking it on and off, and said the lighter was for resident use. One resident, with a diagnosis of Alzheimer's disease or dementia was confused and could not negotiate a path to safety even with staff prompting. Two other residents had mental illness related diagnoses. One had a diagnosis of mental retardation and the other resident was blind and had difficulty speaking. Decorations blocked one fire extinguisher. Electrical adapters and extension cords were not being used correctly. The facility census was 22.
Facility: Medicalodge of Nevada Nevada, MO 100-Bed Skilled Nursing Facility Date of Notice: November 2007	Owner: Medicalodges, Inc. Operator: Same Registered Agent: C T Corporation System	Legal Action: Class II Notice of Noncompliance
Description: A complaint investigation was completed on 11/02/07. The facility was not in substantial compliance with participation requirements. The facility failed to ensure each resident receives adequate supervision to prevent accidents. On 11/01/07 facility staff assisted one resident into the shower room for a bath. The staff left the resident unattended and did not return until an hour and 50 minutes later when the resident was not found in his/her room during bed checks. The resident was found at 11:00 p.m., in the bathtub unresponsive with first and second degree burns from the shoulders down. The resident was transported to the local hospital then life flighted to another area hospital, where the resident expired on 11/04/07.
Facility: Silver Oak Senior Living of Nevada Nevada, MO 57-Bed Residential Care Facility Date of Notice: December 2007	Owner: Not Listed Operator: Silver Oak Senior Living Management Co., LLC Registered Agent: Ken Hanne	Legal Action: Uncorrected Class II Notice of Noncompliance
Description: A licensure inspection was completed on 9/5/07. The facility was not in substantial compliance with participation requirements. A revisit was completed on 11/26/07. The facility failed to ensure poisonous or toxic materials were stored in a locked cabinet and not accessible to residents. Additional deficiencies were cited in the area of Administration and Resident Care Requirements for not ensuring staff were tested for Tuberculosis Screening prior to employment and ensure compliance with all laws and regulations by failing to obtain a license through the Department of Mental Health when caring for residents with mental retardation, mental illness or developmental disabilities.
Facility: Eldorado Rest Haven, Inc. El Dorato Springs, MO 60-Bed Residential Care Facility Date of Notice: December 2007	Owner: Curry, Nadine Operator: El Dorado Rest Haven, Inc. Registered Agent: James L. Curry	Legal Action: Class I Notice of Noncompliance
Description: The facility failed to ensure four residents (Residents #1, #2, #3, and #4) could make an unassisted pathway to safety within five minutes after being physically and verbally prompted to respond to the fire alarm, and failed to ensure one resident (Resident #6) would be able to make a pathway to safety, without assistance.
Facility: Autumn Oaks Caring Center Mountain Grove, MO 120-Bed Skilled Nursing Facility Date of Notice: December 2007	Owner: Mountain Grove #1, Inc. Operator: Mountain Grove #2, Inc. Registered Agent: Clifton L. Shirrell	Legal Action: Class I Notice of Noncompliance
Description: The facility failed to ensure a fire alarm system with approved components, devices or equipment is installed according to NFPA 72, National Fire Alarm Code to provide effective warning of fire in any part of the building. The facility upgraded the fire alarm system on 1/26/07, which included a new addressable panel and smoke detectors. Facility staff performed a fire drill on 1/30/07 and noted all the alarms were not sounding. On 11/16/07, the fire alarm system was activated. The facility had a total of 11 alarm bells connected to the alarm panel. Of the 11, only one bell rang continuously (kitchen area) during the fire alarm system test. The fire alarm did not provide adequate notice to occupants of a fire emergency so that evacuation or other appropriate action could be instituted.
Facility: Kabul Nursing Homes, Inc. Cabool, MO 99-Bed Skilled Nursing Facility Date of Notice: December 2007	Owner: Kabul Nursing Homes, Inc. Operator: Same Registered Agent: Debra Dotson	Legal Action: Class II Notice of Noncompliance
Description: The facility staff failed to notify the physician when unable to obtain PT/INR (used to determine the clotting tendency of blood) labs daily per the physician's order for one resident (Resident #1) and continued to administer Lovenox and Coumadin (blood thinners) to Resident #1 without knowledge of current lab values resulting in the immediate hospitalization of Resident #1 with critically high PT/INR lab results obtained three days after admission.
Facility: Clinton Healthcare & Rehab Center Clinton, MO 120-Bed Skilled Nursing Facility Date of Notice: December 2007	Owner: Mo-An of Kansas & Missouri, LLC Operator: Clinton No. 1, Inc. Registered Agent: Clifton L. Shirrell	Legal Action: Class I Notice of Noncompliance
Description: The facility failed to assess and identify a pressure sore on the left outer ankle until it developed into a stage III pressure sore, failed to obtain timely treatment orders, failed to implement the correct treatment order, failed to obtain treatment orders for a stage II pressure sore on the bottom of Resident #4's left foot, and the facility failed to appropriately reposition five residents (Residents #9, #8, #1, #2, and #10) at risk for pressure sore development in a sample selection of 11 selected residents.

ST. LOUIS REGION
Facility: Tanglewood Care Center Pacific, MO 12-Bed Residential Care Facility Date of Notice: January 2007	Owner: Not Listed Operator: Not Listed Registered Agent: Not Listed	Legal Action: DENIAL OF LICENSURE
Description: The operator has failed to provide a complete application, including all required attachments, demonstrating financial capacity to operate the facility. The operator failed to provide additional information related to the application within (10) working days of the change or of SLTC's request.
Facility: Tanglewood Care Center Pacific, MO 12-Bed Residential Care Facility Date of Notice: February 2007	Owner: Not Listed Operator: Not Listed Registered Agent: Not Listed	Legal Action: RECISSION OF DENIAL AND RE-DENIAL OF APPLICATION FOR LICENSURE
Description: The operator has failed to provide a complete application, including all required attachments, demonstrating financial capacity to operate the facility. The operator failed to provide additional information related to the application within 10 working days of the change or of SLTC's request. The facility has had a history of chronic noncompliance with SLCR standards between September 2002 and present as identified in Statements of Deficiencies previously provided to the facility and the Statement of Deficiencies enclosed with this letter. (Letter on file with MCQC).
Facility: Lakewood Care Center Pacific, MO 12-Bed Residential Care Facility Date of Notice: January 2007	Owner: Converse, Richard & Audrey Operator: Not Listed Registered Agent: Not Listed	Legal Action: DENIAL OF LICENSURE
Description: The operator has failed to provide a complete application, including all required attachments, demonstrating financial capacity to operate the facility. The operator failed to provide additional information related to the application within (10) working days of the change or of SLTC's request.
Facility: Lakewood Care Center Pacific, MO 12-Bed Residential Care Facility Date of Notice: February 2007	Owner: Converse, Richard & Audrey Operator: Not Listed Registered Agent: Not Listed	Legal Action: RECISSION OF DENIAL AND RE-DENIAL OF APPLICATION FOR LICENSE
Description: The operator has failed to provide a complete application, including all required attachments, demonstrating financial capacity to operate the facility. The operator failed to provide additional information related to the application within 10 working days of the change or of SLTC's request. The facility and the operator are not in substantial compliance with the provisions of sections 198.003 to 198.096 and the standards established thereunder. The facility has had a history of chronic noncompliance with SLCR standards between September 2002 and present as identified in Statements of Deficiencies previously provided to the facility and the Statement of Deficiencies enclosed with this letter. (Letter on file with MCQC).
Facility: Converse Home Florissant, MO 12-Bed Residential Care Facility Date of Notice: January 2007	Owner: Converse, Richard & Audrey Operator: Not Listed Registered Agent: Not Listed	Legal Action: DENIAL OF LICENSURE
Description: The operator has failed to provide a complete application, including all required attachments, demonstrating financial capacity to operate the facility. The operator failed to provide additional information related to the application within (10) working days of the change or of SLTC's request.
Facility: Autumn View Gardens at Schuetz Road St. Louis, MO 100-Bed Assisted Living Facility Date of Notice: February 2007	Owner: Not Listed Operator: Bethesda Foundation Registered Agent: C T Corporation System	Legal Action: Class I Notice of Noncompliance
Description: The facility failed to maintain an adequate number of staff in the facility on the night shift for 16 out of 20 night shifts reviewed during the month of 1/07. Facility staff failed to have sufficient staff to monitor and provide care to meet the needs of 14 residents and meet the staffing requirements for fire safety. Also, the facility staff failed to meet the needs of three residents who voiced thoughts of suicide. One resident stated he/she was going to kill him/herself after the holidays. The facility did hospitalize the resident, but failed to monitor or develop an interventional plan to address the resident's earlier suicidal ideations. Staff found the resident dead in his/her room on 1/5/07, after staff had not seen the resident for approximately 13 hours. The facility staff failed to notify the physicians or monitor two other residents who voiced suicidal thoughts.
Facility: Alexian Brothers Lansdowne Village St. Louis, MO 80-Bed Skilled Nursing Facility Date of Notice: February 2007	Owner: Not Listed Operator: Alexian Brothers Lansdowne Village Registered Agent: C T Corporation	Legal Action: Class I Notice of Noncompliance
Description: The facility failed to provide the necessary care and services. Facility staff failed to ensure the resident's physician understood the resident's critical laboratory values, monitor the resident, follow physician orders and keep the physician informed of the resident's status. The resident was hospitalized on 12/26/06 and diagnoses (sic) with severe dehydration and a urinary tract infection. The resident expired on 2/07/07.
Facility: Carrie Elligson Gietner Home St. Louis, MO 120-Bed Skilled Nursing Facility Date of Notice: February 2007	Owner: GMG Properties LLC Operator: GMG, Inc. Registered Agent: Susan Makhamreh	Legal Action: Class I Notice of Noncompliance
Description: The facility failed to provide the necessary care and services to two residents. Facility staff failed to provide cardiopulmonary resuscitation to two residents who were unresponsive and had orders to resuscitate. One resident was in the dining room with staff, who observed the resident become unresponsive. The other resident was found unresponsive in his/her room and CPR was not initiated. In addition, 911 was not called for either resident.
Facility: Normandy Nursing Center St. Louis, MO 116-Bed Skilled Nursing Facility Date of Notice: February 2007	Owner: Creative Health Care Services St. Louis Operator: Normandy Associates, Inc. Registered Agent: Kerry Kauffmann	Legal Action: Class I Notice of Noncompliance
Description: The facility failed to provide adequate oversight and supervision. Facility staff failed to develop and implement interventions to address one resident's history of alcohol abuse. On several occasions the resident was found on the street intoxicated and transferred to the emergency room. On at least one of these occasions the resident sustained an injury, which required sutures.
Facility: Converse Home Florissant, MO 12-Bed Residential Care Facility Date of Notice: April 2007	Owner: Converse, Richard & Audrey Operator: Converse Residential Adult Home Registered Agent: Husch Registered Agent, Inc.	Legal Action; Class I Notice of Noncompliance
Description: Based on observation and interview, the facility failed to ensure the manager intervened on behalf of the residents when an employee was verbally and mentally abusive to nine residents. Based on observation and interview, the facility failed to ensure the manager responded when an employee's actions adversely affected the residents for nine of nine sampled residents.
Facility: Brentmoor Retirement Community St. Louis, MO 36-Bed Residential Care Facility Date of Notice: June 2007	Owner: Brentmoor Retirement Community LLC Operator: Brentmoor Delmar-SPVEF, LLC Registered Agent: Lisa Pool Byrne, Esq.	Legal Action: Uncorrected Class II Notice of Noncompliance
Description: A licensure inspection was completed on 3/27/07. The facility was not in substantial compliance with participation requirements. A revisit was completed on 6/13/07. The facility staff failed to ensure one resident was physically capable of negotiating a normal path to safety in the event of a fire or other emergency.
Facility: Abbey Care Center St. Louis, MO 126-Bed Skilled Nursing Facility Date of Notice: August 2007	Owner: J & J Assoc., LLC Operator: Fairfield Nursing and Rehab, Inc. Registered Agent: Charlotte Stutts	Legal Action: Uncorrected Class II Notice of Noncompliance
Description: A survey was completed on 6/21/07. The facility was not in substantial compliance with participation requirements. A revisit was completed on 8/09/07. The facility staff failed to: Maintain a clean, comfortable and homelike environment in eight of ten sampled resident rooms, three resident accessible corridors and one beauty parlor. Provide adequate pain control to one resident who experienced immense pain, according to facility staff in his/her left hip. Provide appropriate catheter care for two sampled residents with indwelling urinary catheters. Provide adequate care to minimize the risk of accidents and/or injuries when using a mechanical lift for two resident transfers. Ensure floors were clean and free of sticky wax build-up. Provide pest control of gnats, flies and ants in the facility.
Facility: Whispering Oaks Health Care Center Wildwood, MO 70-Bed Residential Care Facility Date of Notice: August 2007	Owner: Not Listed Operator: Whispering Oaks Health Care Center, Inc. Registered Agent: Eric F. Fink, Jr.	Legal Action: Uncorrected Class II Notice of Noncompliance
Description: A licensure inspection was completed on 4/27/07. The facility was not in compliance with participation requirements. A revisit was completed on 7/24/07. The facility staff failed to follow physician orders and administer inhalers to three residents as ordered by the residents' physician and failed to assess one resident's blood pressure prior to administering medication. The facility staff failed to obtain physician orders for four residents to administer their own medications and/or store medications in their rooms. Facility staff failed to make repairs to ceiling tiles, which were stained, bowed and/or had holes, replace scuffed and marred doors exposing the wood underneath. Also, the facility failed to ensure resident trust fund accounts were accurate by reconciling the resident trust fund bank account for the months of May and June 2007.
Facility: Oak Park Nursing Center St. Louis, MO 120-Bed Skilled Nursing Facility Date of Notice: September 2007	Owner: Oak Park Real Estate, LLC Operator: Berthold Nursing Center, Inc. Registered Agent: Clifton L. Shirrell	Legal Action: Class I Notice of Noncompliance
Description: The facility failed to provide a self-closing device into which staff could empty ashes and cigarette butts. The facility failed to fully assess the need for physical restraints, and to ensure that residents wore the least restrictive restraint possible. The facility failed to provide clean walls, floors, and equipment for residents. The facility failed to provide housekeeping and maintenance services necessary to provide a clean, orderly interior. The facility failed to provide appropriate and timely wound care for one resident. The facility failed to provide appropriate catheter care. The facility failed to serve a therapeutic diet as ordered for the residents. The facility failed to follow approved puree and enhanced cereal recipes when preparing food for residents and failed to serve dietitian approved substitute menu items for residents. The facility failed to serve cold foods at 45 degrees Fahrenheit or colder and failed to hold potentially hazardous foods at 140 degrees (F) or above.
Facility: Parkview Residential Care Crystal City, MO 52-Bed Residential Care Facility Date of Notice: September 2007	Owner: Jean-Baptist, Philippe & Debra Hahn Operator: DMP Enterprises, Inc. Registered Agent: Mark C. Goldenberg	Legal Action: Class II Notice of Noncompliance
Description: On 9/05/07 a complaint investigation was completed. The facility staff failed to assess and meet the needs of one resident who had a decline in mental status and exhibited inappropriate behaviors. The operations manager stated the resident's mental status had deteriorated and the facility could not meet the resident's needs. Interviews with emergency room physicians indicated the resident required a higher level of care. In addition, the facility failed to provide adequate oversight and supervision of the resident when the resident left the facility without staff knowledge on several occasions. On 8/11/07, the police picked up the resident for attempting to gain entry into a business located 2.6 miles from the facility and was transported to the hospital emergency room. The resident was wearing a long sleeve shirt and winter coat when he/she left the facility, even though the temperature that day was 100 degrees Fahrenheit. The resident's temperature was 106.2 degrees Fahrenheit and was admitted to the hospital with a diagnosis of hyperthermia (heatstroke).
Facility: Delmar Gardens of Meramec Valley Fenton, MO 190-Bed Skilled Nursing Facility Date of Notice: September 2007	Owner: Not Listed Operator: Delmar Gardens of Meramec Valley, LLC Registered Agent: Husch Registered Agent, Inc.	Legal Action: Class I Notice of Noncompliance
Description: A complaint investigation was completed on 9/10/07. The facility staff failed to properly assess the use of side rails and develop appropriate interventions to protect one resident from injury. Review of the resident's medical record showed incomplete restraint assessments, no physician's order for side rail use and the use of a personal alarm in the wheelchair and bed as an audible alert for nursing staff. On 8/03/07 facility staff transferred the resident from the wheelchair to bed and did not apply the personal alarm in bed. At 10:20 p.m., facility staff found Resident #1 with his/her neck against a side rail and his/her body hanging down to the floor, resulting in the resident's death. Investigation by the medical examiner revealed the resident's cause of death was due to accidental positional asphyxiation.
Facility: Rosewood Care Center St. Louis County, Inc. St. Louis, MO 120-Bed Skilled Nursing Facility Date of Notice: December 2007	Owner: Not Listed Operator: Rosewood Care Center of St. Louis County, Inc. Registered Agent: Steven M. Hamburg	Legal Action: Uncorrected Class II Notice of Noncompliance
Description: The facility failed to administer an anti-infective medication as ordered by the physician, and notify the physician of the resident's change in condition for one resident.
Facility: Page Manor St. Louis, MO 49-Bed Assisted Living Facility Date of Notice: December 2007	Owner: Malik, Saleh M. Operator: Malik Home, LLC Registered Agent: Saleh Malik	Legal Action: Uncorrected Class II Notice of Noncompliance
Description: A licensure inspection was completed on 9/13/2007, the facility was not in compliance with participation requirements. A revisit was completed on 11/21/2007. The facility failed to conduct premove-in screening prior to admission for one resident with a history of suicide attempts. Facility staff admitted the resident on 9/11/2007 but failed to complete the screening until 9/12/2007.
Facility: St. Elizabeth Healthcare & Rehabilitation Center Florissant, MO 150-Bed Skilled Nursing Facility Date of Notice: December 2007	Owner: Not Listed Operator: St. Elizabeth Healthcare & Rehabilitation Center, LLC Registered Agent: Mark S. Rubin	Legal Action: Uncorrected Class II Notice of Noncompliance
Description: The facility failed to follow their behavioral emergency policy to ensure one resident (Resident #39) was free from physical, mental abuse, involuntary seclusion and discipline, when staff removed the resident from his/her room against the resident's will and physically forced the resident to go to the secure unit. Staff grasped the resident by the upper arms and forced the resident approximately 25-30 feet through the hallway to the nurses' station on 11/12/07. The resident sustained bruising under his/her upper arms. The facility also failed to immediately notify the Administrator, report to the proper authorities and thoroughly investigate when the resident sustained bruising under his/her upper arms from being physically forced by staff through the hallway.
Facility: Affton House Affton, MO 19-Bed Residential Care Facility Date of Notice: December 2007	Owner: Not Listed Operator: Laura Roques Registered Agent: Not Listed	Legal Action: Class II Notice of Noncompliance
Description: A licensure inspection was completed on 11/27/07. The facility was not in substantial compliance with participation requirements. A revisit and complaint investigation was completed on 12/11/07. The facility failed to have the electrical wiring inspected since reopening in July 2007. The facility did not obtain a license with Department of Mental Health as required when caring for residents with mental illness and/or Mental Retardation as required in statute. In addition the facility staff failed to provide adequate supervision and oversight for one resident who left the facility for a hospital day program and upon his/her return to the facility told staff that he/she had ingested 499 aspirins. While at the day program, the resident talked about purchasing a lot of aspirin. The day program staff called the facility to report what the resident talked about and informed the facility to monitor the resident upon his/her arrival to the facility. The facility did not know the residents whereabouts from the time he/she got off the transportation van until the time he/she reentered the facility. The resident purchased five bottles of aspirin at a gas station/store located close to the facility. The resident expired on 10/18/07 after hospitalization for ingesting the 499 aspirin. Review of the facility history and cited violations and the circumstances the Section for Long Term Care Regulations has determined to deny the facility's application for a license to operate.