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.