MCQC Nursing Home Violations 2006

CENTRAL REGION
Facility: Ashley Manor Care Center Boonville, MO 52-Bed, Skilled Nursing Facility Date of Notice: January 2006		Owner: Ashley Manor, Inc. Operator: Ashley Manor, Inc. Registered Agent: Hal F. Juckette		Legal Action: Class I Notice of Noncompliance
Description: A survey was completed on 1/06/06. The facility was not in substantial compliance with participation requirements in the area of Life Safety. The facility staff failed to verify receipt of the fire alarm signal to the monitoring company, when conducting monthly tests of the fire alarm, in a building without a complete sprinkler system. Additional violations were cited during the course of the survey, which are listed on the Statement of Deficiencies.
Facility: Jefferson City Nursing & Rehab Center Jefferson City, MO 120-Bed Skilled Nursing Facility Date of Notice: May 2006	Owner: HCRI Missouri Properties LLC Operator: Jefferson City Nursing & Rehab Ctr., LLC Registered Agent: CSC – Lawyers Incorporating Service Company		Legal Action: Uncorrected Class II Notice of Noncompliance
Description: A survey was completed on 3/3/06. The facility was not in substantial compliance with participation requirements. A revisit was completed on 4/27/06. The facility staff failed to prevent and safeguard the commingling of residents' personal funds with facility operating funds, to credit and post all interest earned on resident funds held in the facility operating account, to maintain a full, complete and separate accounting of residents and to notify residents that the balance in the residents trust fund account had reached $200 less than the SSI resource limit. The facility staff failed to obtain adequate surety for the protection of resident funds held in trust and managed by the facility. Also, the facility staff failed to document and provide treatments, obtain laboratory tests and document administration of health shakes as ordered by the resident's physician.
Facility: Katy Manor Pilot Grove, MO 60-Bed Skilled Nursing Facility Date of Notice: May 2006	Owner: Cooper County Nursing Home District Operator: Same Registered Agent: Not Listed		Legal Action: Class I Notice of Noncompliance
Description: The facility staff failed to assess and monitor side rails to prevent one resident from climbing over the side rails. The resident fell to the floor hitting his/her head and expired. Facility staff failed to assess and monitor additional residents who used side rails that did not treat a medical symptom and prevented the residents from rising. Also, facility staff failed to provide adequate supervision and assistive devices to prevent falls.
Facility: Ashbury Heights of Jefferson City Jefferson City, MO 12-Bed Residential Care Facility Date of Notice: June 2006	Owner: Furnell Investments Inc. Operator: Bristol Care Inc. Registered Agent: David C. Furnell		Legal Action: Uncorrected Class II Notice of Noncompliance
Description: A licensure inspection was completed on 4/28/06. The facility was not in substantial compliance with participation requirements. A revisit was completed on 6/21/06. The facility staff failed to ensure every supply outlet or connection to a water fixture was protected against backflow. In addition, the facility staff failed to maintain freezer temperatures of zero degrees Fahrenheit or below.
Facility: Bristol Manor of Fulton Fulton, MO 12-Bed Residential Care Facility Date of Notice: July 2006	Owner: Not Listed Operator: Bristol Care, Inc. Registered Agent: David C. Furnell		Legal Action: Uncorrected Class II Notice of Noncompliance
Description: A licensure inspection was completed on 5/26/06. The facility was not in compliance with participation requirements. A revisit was completed on 7/12/06. The facility staff failed to keep different categories of poisonous or toxic materials stored in locked locations physically separate from each other.
Facility: Ashbury Heights of Laurie Laurie, MO 12-Bed Residential Care Facility Date of Notice: July 2006	Owner: Not Listed Operator: Bristol Care Inc. Registered Agent: David C. Furnell		Legal Action: Uncorrected Class II Notice of Noncompliance
Description: A licensure inspection was completed on 5/31/06. The facility was not in compliance with participation requirements. A revisit was completed on 7/20/06. The facility staff failed to ensure emergency lights were in proper working order, failed to ensure a safe and effective medication administration.
Facility: Autumn Meadows Linn, MO 132-Bed Skilled Nursing Facility Date of Notice: August 2006	Owner: Piedra, Enrique and Cheribeth Operator: Autumn Meadows, LLC Registered Agent: John H. Simmons		Legal Action: Class I Notice of Noncompliance
Description: The facility failed to provide adequate supervision and assistive devices for one dependent resident, utilizing a Geri-chair, resulting in injury to the resident. On 7/3/06 the resident sustained a skin tear and bruised nail to his/her left middle finger. The facility investigation did not identify the cause of the injury and staff failed to update the plan of care to prevent further injuries. On 7/18/06, staff assisted the resident from a reclined position in the Geri-chair to an upright position and caught the resident's left middle finger in the metal parts positioned below the Geri-chair seat. The resident sustained a traumatic partial amputation to the left middle finger.
Facility: Fulton Nursing & Rehab Fulton, MO 110-Bed Skilled Nursing Facility Date of Notice: October 2006	Owner: Heritage Lane Partnership Operator: Not Listed Registered Agent: Not Listed		Legal Action: Uncorrected Class II Notice of Noncompliance
Description: Facility staff failed to assess and implement appropriate care in a timely manner for one resident with pressure sores.
Facility: Villa Marie Skilled Nursing Facility Jefferson City, MO 120-Bed Skilled Nursing Facility Date of Notice: November 2006	Owner: SSM Regional Health Services Operator: Otke-Villa, LLC Registered Agent: Husch Registered Agent, Inc.		Legal Action: Uncorrected Class II Notice of Noncompliance
Description: The facility failed to re-order medication for one resident and failed to record vital signs prior to the administration of medication as ordered by the physician. The facility census was 99 residents.

KANSAS CITY REGION
Facility: Ashton Court Care & Rehab Centre Liberty, MO 140-Bed Skilled Nursing Facility Date of Notice: January 2006	Owner: FCSCD Properties I, LLC Operator: Ashton Court Healthcare, LLC Registered Agent: CSC-Lawyers Incorporating Service Company		Legal Action: Uncorrected Class II Notice of Noncompliance
Description: A survey was completed on 11/18/05. A revisit was completed on 1/4/06. The facility was not in substantial compliance with participation requirements in the following areas: Facility staff failed to notify a resident's family member of a change in condition that resulted in hospitalization for one resident. Staff failed to clean and maintain floors, walls, doors, resident use equipment and ventilation system. Staff failed to assure that the resident's catheter bag and catheter tubing remained off the floor for four residents.
Facility: Golden Acres Independence, MO 16 Bed Residential Care Facility Date of Notice: January 2006		Owner: Jones, Jill Operator: Teresa Henry Registered Agent: Not Listed	Legal Action: Uncorrected Class II Notice of Noncompliance
Description: A licensure inspection was completed 9/20/05. A revisit was conducted 12/02/05. A second revisit was completed 1/18/06. The facility was not in substantial compliance with participation requirements in the following areas: Facility staff failed to maintain resident use bathrooms free of odors. Staff failed to maintain walls and ceilings in good repair in one resident use bathroom. Staff failed to maintain complete personnel records for facility employees. Facility staff failed to obtain a surety bond in a form approved by the Division while holding funds for residents. Staff failed to maintain a written account of personal funds transactions for each resident.
Facility: Woodbine Healthcare & Rehab Centre Gladstone, MO 300-Bed Skilled Nursing Facility Date of Notice: January 2006		Owner: Not Listed Operator: Woodbine Healthcare, LLC Registered Agent: CSC-Lawyers Incorporating Service Company	Legal Action: Uncorrected Class II Notice of Noncompliance
Description: An annual survey was completed on 10/28/05. A revisit was completed on 12/28/05. The facility was not in substantial compliance with participation requirements in the following areas: Facility staff failed to follow physician orders for one resident. Provide appropriate care to prevent infection for one resident with a urinary catheter. Assure staff transferred one resident in a safe manner to prevent injury. Assure staff washed their hands when going from soiled to clean tasks when providing care to two residents.
Facility: Park Place Care Center Raytown, MO 120-Bed Skilled Nursing Facility Date of Notice: March 2006		Owner: William Marrion Trust Operator: Deaconess Long Term Care of Missouri, Inc. Registered Agent: The Corporation Company	Legal Action: Uncorrected Class II Notice of Noncompliance
Description: The facility failed to administer pain medication prior to wound treatment and failed to document reasons for administration of PRN medication. The facility also failed to ensure one resident's abilities in ADLs did not diminish unless clinical condition demonstrates it was unavoidable.
Facility: The Greens at Creekside Kansas City, MO 180 Bed Skilled Nursing Facility Date of Notice: March 2006		Owner: Chaudhary International, Inc. Operator: Fayjay, Inc. Registered Agent: Stephanie G. Hazelton	Legal Action: Class I Notice of Noncompliance
Description: A revisit was completed at the facility on 3/7/06. The facility was not in substantial compliance with participation requirements. The facility staff failed to address the progression of a worsening, infected Stage IV pressure sore with exposed bone affecting two residents. Also, the facility failed to identify, assess and treat pressure sores for six additional residents at risk for developing pressure sores. Additional uncorrected violations were found in the area of quality of care.
Facility: Silver Oak Senior Living at Butler Butler, MO 57 Bed Residential Care Facility Date of Notice: March 2006		Owner: HR Acquisition I Corp. Operator: Silver Oak Senior Living, LC Registered Agent: Not Listed	Legal Action: Class I and Uncorrected Class II Notice of Noncompliance
Description: Class I Citation: The facility was cited for a Class I citation related to their failure to ensure hot water temperatures did not exceed 120 degrees Fahrenheit. Facility documentation showed hot water temperatures documented since 1/1/06 ranged from 121 degrees to 224 degrees in resident rooms and shower rooms. SLTC staff identified the hottest temperature on 3/9/06 at 151.6 degrees. Facility staff had notified the Administrator of the hot water temperatures and the facility failed to put interventions into place to address the situation and safeguard residents. Uncorrected Class II Citations: Facility failed to ensure gas-fired water heaters were installed properly, maintained in good condition, vented, and equipped with a temperature valve. Additionally, the facility failed to ensure one resident, who required the use of a hearing aid to hear the fire alarm had his/her room equipped with an emergency strobe light to alert the resident of an emergency. The facility failed to ensure a licensed Administrator was hired to manage the facility, and to ensure provisions were put into place by current administrative staff to ensure sufficient time and attention were paid to the management of the facility, until a new Administrator was hired and approved to manage the facility.
Facility: Park Place Care Center Raytown, MO 120 Bed Skilled Nursing Facility Date of Notice: March 2006		Owner: William Marrion Trust Operator: Deaconess Long Term Care of Missouri Inc. Registered Agent: The Corporation Company	Legal Action: Uncorrected Class II Notice of Noncompliance
Description: The facility failed to complete ongoing assessments, notify the physician in a timely manner of a change in condition and failed to administer an antibiotic in a timely manner when ordered by the physician for one resident (Resident #1). On 2/1/06, facility staff identified and documented that one resident had a red, raised area on his/her right lower leg. Staff did not notify the physician until 2/26/06 when requested to do so by the family. The physician ordered an antibiotic but the facility did not begin to administer the antibiotic until 2/27/06. On 3/1/06, the resident's family took the resident to the emergency room for evaluation. The hospital physician diagnosed the resident had a deep vein thrombosis (blood clot) in the lower right leg. The facility census was 100 residents.
Facility: Camden Health Center Harrisonville, MO 120-Bed Skilled Nursing Facility Date of Notice: April 2006		Owner: Not Listed Operator: Deaconess Long Term Care of Missouri, Inc. Registered Agent: The Corporation Company	Legal Action: Uncorrected Class II Notice of Noncompliance
Description: The facility failed to correct deficiencies in the following areas: Physical Plant requirements as hot water temperatures in resident use areas exceeded 120 degrees Fahrenheit, wall coverings and paint did not have the proper flame spread rating and the facility failed to ensure that all smoke dampers properly operated upon activation of the fire alarm system; Dietary requirements as the dietary staff did not appropriately prepare pureed food items to a smooth consistency; General Sanitation requirements as the facility failed to provide adequate smoke ventilation in the residents' smoke room and failed to provide the appropriate lid for the grease trap in the kitchen to properly seal the grease trap; Fire Safety standards as the facility installed a new range hood extinguisher and did not tie the extinguisher into the facility fire alarm system and failed to ensure sprinkler heads were properly maintained.
Facility: Waterford South Kansas City, MO 28-Bed Residential Care Facility Date of Notice: May 2006		Owner: Sunshine Villages, Inc. Operator: Sunshine Villages, Inc. Registered Agent: Not Listed	Legal Action: Uncorrected Class II Notice of Noncompliance
Description: SLTC staff completed a revisit on 5/11/06. The facility failed to provide medication as ordered by the physician for 10 residents and failed to verify a physician's order for medication for one resident. The facility census was 26.
Facility: Bristol Manor of Raymore Raymore, MO 12-Bed Residential Care Facility Date of Notice: June 2006		Owner: Not Listed Operator: Bristol Care, Inc. Registered Agent: David C. Furnell	Legal Action: Class I Notice of Noncompliance
Description: The facility failed to inform one resident's physician when one resident repeatedly made possible suicidal statements regarding “not being here much longer” and then, within the week prior to Memorial Day, stated he/she only had five more days. On 5/28/06, staff found the resident dead in his/her bed with a plastic bag taped over his/her head and tape wrapped around his/her legs. The resident's physician verified facility staff had not informed him of the resident's recent statements and if they had, the physician said he would have ordered a psychiatric consult.
Facility: The Greens at Creekside Kansas City, MO 180-Bed Skilled Nursing Facility Date of Notice: June 2006		Owner: Chaudhary International LLC Operator: Fayjay, Inc. Registered Agent: Stephanie G. Hazelton	Legal Action: Class I Notice of Noncompliance
Description: The facility failed to provide appropriate care and services to five residents (Residents #500, #501, #502, #503 and #512). Staff failed to assess and report to the facility's licensed nurse and physicians that two residents (Residents #500 and #502) had a decline in condition. Resident #500 hit his/her head on 5/4/06 and staff failed to inform the licensed nurse until two hours later after the resident's condition began to decline. The resident was admitted to the hospital on 5/4/06 and died on 5/5/06 from complications of the head injury. Resident #502 had a decline in condition on 4/29/06 and staff failed to promptly inform the licensed nurse and physician. The resident was admitted to the hospital on 4/30/06 with a diagnosis consistent with a stroke. The facility failed to treat Resident #503's complaints of severe pain during treatment of multiple pressure sores. Facility staff failed to treat Resident #512's complaints of pain following back surgery. Facility staff failed to adequately care for Resident #501's contracted (shortening and tightening of the muscles) right hand when the fingernails began to burrow into the palm of the resident's hand and failed to provide physician ordered pain medication for seven days. The facility census was 117 residents.
Facility: IHS of KC at Alpine North Kansas City, MO 186-Bed Skilled Nursing Facility Date of Notice: June 2006		Owner: Not listed Operator: IHS of Cliff Manor Inc. Registered Agent: National Corporate Research LTD	Legal Action: Uncorrected Class II Notice of Noncompliance
Description: A survey was completed on 4/3/06. The facility was not in substantial compliance with participation requirements. A revisit was completed on 6/2/06. The facility was not in substantial compliance in the following areas: Failed to update the resident's plan of care to reflect the resident's current needs; Failed to assure the facility staff followed acceptable standards of practice while administering medications and monitor oxygen use; Failed to provide supervised smoking for two residents; Failed to change an ostomy bag in a manner to prevent complications for one resident.
Facility: The Greens at Creekside Kansas City, MO 180-Bed Skilled Nursing Facility Date of Notice: July 2006		Owner: Chaudhary International, Inc. Operator: Fayjay, Inc. Registered Agent: Stephanie G. Hazelton	Legal Action: Class I Notice of Noncompliance
Description: The facility failed to provide appropriate care and services to one resident as facility nursing staff failed to clarify admission orders on 5/2/06 for one resident (Resident #1). Staff failed to determine what the medication was used for, failed to obtain the diagnosis to support the use of the medication and did not verify the dosage amount with the prescribing physician. When Resident #1's condition began to decline, staff did not promptly notify the physician of the changes in condition. On 5/11/06, staff transferred the resident to the hospital and the resident died on 5/19/06. The facility census was 106 residents.
Facility: John Knox Village Care Center Lees Summit, MO 430-Bed Skilled Nursing Facility Date of Notice: August 2006		Owner: John Knox Village Operator: John Knox Village Registered Agent: SHB Registered Agent, Inc.	Legal Action: Uncorrected Class II Notice of Noncompliance
Description: The facility staff failed to implement the facility's nutritional policy and procedure, failed to develop and implement a care plan addressing nutritional needs, failed to routinely monitor weight and oral intake, and failed to provide appropriate assistance during meals for one resident. The facility census was 260 residents.
Facility: Swope Ridge Geriatric Center Kansas City, MO 240-Bed Skilled Nursing Facility Date of Notice: August 2006		Owner: City of Kansas City Operator: Care Center of Kansas City Registered Agent: Dorothy Fauntleroy	Legal Action: Class I Notice of Noncompliance
Description: A survey was completed on 6/9/06. The facility was not in compliance with participation requirements. A revisit was completed on 7/28/06. The facility failed to assure staff used appropriate transfer techniques for one resident to prevent potential injury to the resident. Staff also failed to provide appropriate assistance and assistive devices to one resident to enable that resident to eat independently and failed to reposition, exercise and toilet two residents who required physical restraints when in their wheelchair.
Facility: Lutheran Nursing Home Concordia, MO 120-Bed Skilled Nursing Facility Date of Notice: August 2006		Owner: Lutheran Nursing Home Operator: Same Registered Agent: Raymond Frerking	Legal Action: Class I Notice of Noncompliance
Description: The facility staff failed to transfer and ambulate one resident (Resident #1) according to the resident's plan of care and facility policy. The CNA did not use a gait belt to transfer or assist the resident, who used a walker, to walk to the bathroom. The CNA did not provide the resident support to stand while the CNA opened the bathroom door. The resident fell backwards and hit his/her head on the floor. The resident sustained a scalp laceration, multiple bleeding sites within the brain and skull fracture. The facility transferred the resident to the hospital on 7/25/06. The resident died on 7/30/06 from complications resulting from the traumatic brain injury.
Facility: Park Place Care Center Raytown, MO 120-Bed Skilled Nursing Facility Date of Notice: August 2006		Owner: William Marrion Trust Operator: Deaconess Long Term Care of Missouri, Inc. Registered Agent: The Corporation Co.	Legal Action: Class I Notice of Noncompliance
Description: The facility failed to provide protective oversight and a safe and effective system of medication administration to one resident. A licensed nurse applied a 75 mcg/hr (micrograms per hour) Fentanyl patch (Duragesic, a narcotic pain medication) to the wrong resident (Resident #1) on 8/2/06 at 11:30 a.m. By 6:00 p.m. Resident #1 had a significant decline in condition and was non-responsive and sent to the emergency room. Resident #1 was hospitalized from 8/2-6/06 for treatment of a Fentanyl overdose. The facility census was 103 residents.
Facility: Life Care Center of Grandview Grandview, MO 172-Bed Skilled Nursing Facility Date of Notice: August 2006		Owner: Grandview Medical Investors LLC Operator: United Investors Limited Partnership, dba United Methodist Investments Registered Agent: CT Corporation System	Legal Action: Class I Notice of Noncompliance
Description: The facility failed to provide nursing care in accordance with one resident's condition and acceptable nursing practice. On 7/15/06, facility staff failed to safely transfer one resident when using a mechanical lift and the resident fell from the lift 2-1/2 feet to the floor. Facility staff failed to assess, monitor, and reassess the resident or notify the physician after the fall. Staff did not notify the physician until 7/17/06 after the resident lost feeling and movement of both legs. Staff transferred the resident to the emergency room where the physician determined the resident was paralyzed below the chest.
Facility: Rosewood Health Center Independence, MO 300-Bed Skilled Nursing Facility Date of Notice: September 2006		Owner: Resthaven, Inc. Operator: The Groves Registered Agent: Karen E. Minton	Legal Action: Uncorrected Class II Notice of Noncompliance
Description: The facility failed to correct violations in the area of Administration and Resident Care requirements. The facility failed: To immediately report to the state agency and to the administrator an allegation of physical abuse and failed to ensure further potential abuse would not occur; to follow physician's orders; to provide supervision and assistive devices to prevent accidents; to provide feeding assistance at meal times; to provide appropriate incontinence care and to handle urinary catheters appropriately.
Facility: White Ridge Health Center Lee's Summit, MO 60-Bed Skilled Nursing Facility Date of Notice: September 2006		Owner: Not Listed Operator: Deaconess Long Term Care of Missouri, Inc. Registered Agent: The Corporation Company	Legal Action: Class I Notice of Noncompliance
Description: The facility staff failed to provide protective oversight to all residents residing in the facility on the evening shift on 8/11/06 when the only licensed nurse (a licensed practical nurse) on duty left the facility for approximately one hour. During the shift report on 8/11/06, the day charge nurse informed the licensed practical nurse that one resident on hospice was “actively dying.” Another resident had a gastrostomy feeding tube, two wound vacuums, required suctioning as needed, and received narcotic pain management every four hours. In addition, the facility identified seven residents as elopement risks, four other residents received hospice services and 19 residents with a full code status. Other unlicensed nursing staff in the facility did not know whom to contact while the licensed nurse was not at the facility. The facility census was 56 residents.
Facility: Medicalodge of Butler Butler, MO 110-Bed Skilled Nursing Facility Date of Notice: September 2006		Owner: Medicalodges, Inc. Operator: Same Registered Agent: C T Corporation System	Legal Action: Uncorrected Class II Notice of Noncompliance
Description: Facility staff failed to wash their hands appropriately while providing peri care for two of nine sampled residents.
Facility: Oak Grove Nursing & Rehab Oak Grove, MO 90-Bed Skilled Nursing Facility Date of Notice: October 2006		Owner: Grove Oak – Cal Assoc., LP Operator: N & R of Oak Grove, LLC Registered Agent: Charlotte Stutts	Legal Action: Uncorrected Class II Notice of Noncompliance
Description: A survey was completed on 8/11/06. The facility was not in substantial compliance with participation requirements. A revisit was completed on 9/29/06. The facility staff failed to: Follow a physician's order to obtain laboratory work for one resident; assess, treat and evaluate the effectiveness of pain medication for one resident with repeated complaints of pain and ensure potassium-sparing medications were not administered to a resident who had a diagnosis of electrolyte imbalance and who experienced critically elevated potassium levels previously affecting one resident; provide appropriate perineal care for a resident with an indwelling catheter in a manner to prevent the development of a urinary tract infection, and assess, report, and treat a urinary tract infection in a timely manner; provide appropriate care to one resident at risk for falls, resulting in a fall with a head laceration requiring sutures, and complete assessments every shift following the fall; ensure a resident received care supervised by a physician when his/her potassium levels became critically elevated affecting (sic); report critically elevated laboratory results to one resident's physician.
Facility: The Greens at Creekside Kansas City, MO 180-Bed Nursing Facility Date of Notice: November 2006		Owner: Chaudhary International LLC Operator: Fayjay, Inc. Registered Agent: Stephanie G. Hazelton	Legal Action: Class I Notice of Noncompliance
Description: Facility staff failed to provide individualized care and services and protective oversight on the 40-bed dementia Special Care Unit for a resident with a history of sexually aggressive behavior (Resident #1) and for a resident with wandering behaviors (Resident #2). Checks were to be completed every 15 minutes, were not clearly assigned to staff and were not completed on an on-going basis. On the evening shift on 10/20/06 a resident with a history of sexually aggressive behavior (Resident #1) was found in his/her bed on top of a confused resident with wander behaviors (Resident #2).
Facility: Blue River Care Center Kansas City, MO 160-Bed Skilled Nursing Facility Date of Notice: November 2006		Owner: Blue River Real Estate LLC Operator: Blue River Care Center LLC Registered Agent: Raymore Healthcare Inc.	Legal Action: Class I Notice of Noncompliance
Description: The facility failed to provide nursing care in accordance to the resident's condition and consistent with acceptable nursing practice. On 10/25/06 at 8:00 a.m., one resident received injuries of unknown origin to the left lower leg and right upper leg. Staff failed to transfer the resident appropriately to provide support to both legs and licensed nursing staff failed to fully inform the resident's physician of the injuries which delayed the resident receiving the appropriate care and treatment. Licensed nursing staff also ordered an x-ray of the resident's right upper leg without a physician's order. On 10/25/06, staff transferred the resident to the emergency room. The physician diagnosed the resident had fractures to the right upper leg and fractures to both bones of the left lower leg.
Facility: Carmel Hills Healthcare & Rehab Center Independence, MO 156-Bed Skilled Nursing Facility Date of Notice: November 2006		Owner: Not Listed Operator: Carmel Hills Healthcare & Rehabilitation Registered Agent: National Registered Agents, Inc.	Legal Action: Uncorrected Class II Notice of Noncompliance
Description: Based on interviews and record review, the facility failed to notify the physician of a change of condition of one resident (Resident #1). Resident #1 fell twice on 10/3/06 and once on 10/5/06 and 10/6/06. Family members informed a licensed nurse during the evening on 10/8/06 when Resident #1's left leg and foot became cool to touch and swollen and “looked different.” The licensed nurse confirmed the resident's change of condition but did not notify the physician. On 10/9/06 at 8:45 a.m. the day shift licensed nurse assessed the resident and informed the physician. Staff transferred the resident to the emergency room where x-rays showed the resident's pelvis and left femur were fractured. The facility census was 143 residents.
Facility: Jefferson Health Care Lee's Summit, MO 120-Bed Skilled Nursing Facility Date of Notice: November 2006		Owner: DCB Real Estate Partnership Operator: Jefferson Health Care, Inc. Registered Agent: Lonnie G. Hasty	Legal Action: Class I Notice of Noncompliance
Description: Facility staff failed to respond to one resident's emergency situation by not continuing cardiopulmonary resuscitation (CPR) during a medical emergency. According to the resident's medical record, the resident was a full code status. According to Lee's Summit police officers, upon arrival to the facility, staff was not providing the resident with CPR. The resident was transported to the hospital. Upon arrival at the hospital the resident had a pulse for five to ten minutes before he/she expired at the hospital.
Facility: Garden Valley Manor & Rehab, LLC Kansas City, MO 150-Bed Skilled Nursing Facility Date of Notice: November 2006		Owner: Garden Valley Place LLC Operator: Same Registered Agent: Sharo Shirshekan	Legal Action: Uncorrected Class II Notice of Noncompliance and New Class III Violations
Description: The facility failed to identify that the pharmacy should bill the facility for medication expenses. The facility also failed to reimburse the resident for room, board and ancillary charges when the facility should have billed Medicare Part A for these services. The facility failed to assure staff obtained physician ordered laboratory tests in a timely manner for one resident. The facility staff failed to assure physicians received elevated lab results for one resident and symptoms of a urinary tract infection for one resident.
Facility: Carondelet Manor Kansas City, MO 162-Bed Skilled Nursing Facility Date of Notice: December 2006		Owner: Carondelet Health Operator: Carondelet LTC Fac Inc Registered Agent: Timothy O. Kristl	Legal Action: Class I Notice of Noncompliance
Description: Based on observation, interview and record review, facility staff failed to provide adequate assessment for the need and appropriateness of a side rail restraint for one resident (Resident #1) who was confused and did not use the side rails for positioning or improving bed mobility. Facility staff failed to provide adequate supervision for Resident #1, with a history of confusion and having “body parts” hanging over and resting on the side rails, who had an electric bed with side rails and access to bed controls. Staff found Resident #1 dead, with his/her neck trapped between the side rails and mattress. The facility failed to provide staff and Resident #1 instructions for the use of Resident #1's electric bed and the bed side rails that was unique in structure compared to all the other beds in the building. The census was 135 residents.
Facility: Blue Springs Care Center Blue Springs, MO 120-Bed Skilled Nursing Facility Date of Notice: December 2006		Owner: Clark, Jack, Marty & Chris Operator: Blue Springs Care Center Registered Agent: NONE	Legal Action: Uncorrected Class II Notice of Noncompliance
Description: At the revisit conducted 12/11/06, the facility failed to correct the following violations: To establish and maintain, according to general accounting principles a system that prevents the commingling of corporate funds and residents' personal funds; failed to manage and account for the personal funds of the residents deposited with the facility by posting deposits to the resident trust fund account, and to post and deposit interest accrued on each resident's account for the years 2000 to 2006, and to follow the facility admission agreement regarding the handling of resident funds. To obtain an adequate surety bond to protect the resident funds from misappropriation, affecting all 20 current residents with money in the resident trust fund account and with the potential to affect 312 residents with refunds identified as due. To maintain food holding temperatures at safe levels and left food exposed to the environment after use with the potential to affect all 74 residents eating in the facility.

NORTHEAST REGION
Facility: Preferred Family Healthcare Kirksville, MO 57-Bed Residential Care Facility Date of Notice: January 2006	Owner: Preferred Family Healthcare, Inc. Operator: Preferred Family Healthcare, Inc. Registered Agent: Michael T. Schwend		Legal Action: Uncorrected Class II Notice of Noncompliance
Description: At the revisit to 1/5/06 to the annual inspection, the facility failed to immediately correct a fault in the fire alarm system, failed to ensure the smoke stop partition doors would latch properly when tested, and failed to maintain the hot water temperatures within the required range of 105 to 120 degrees Fahrenheit in three of four sampled resident rooms on the second floor.
Facility: Southside Towne House Mexico, MO 12-Bed Residential Care Facility Date of Notice: January 2006	Owner: Braun Enterprises, Inc. Operator: Braun Enterprises, Inc. Registered Agent: Sue Braun		Legal Action: Uncorrected Class II Notice of Noncompliance
Description: The facility failed to have all resident's accounts brought current monthly.
Facility: Bowling Green Residential Care Bowling Green, MO 24-Bed Residential Care Facility Date of Notice: February 2006		Owner: Amos, Rickie L & Ann L Operator: None Registered Agent: None	Legal Action: Class I Notice of Noncompliance
Description: The operator failed to notify the local fire department and DHSS when the fire alarm system malfunctioned and was turned off. The operator also failed to implement an approved fire watch with a designated staff person until the fire alarm system was repaired. On 1/24/06 at 9:30 p.m., the facility's fire alarm system malfunctioned. The operator was unable to fix the problem and shut down the fire alarm system on 1/25/06 at 5:30 p.m. The fire alarm system was not repaired until 1/26/06 at 1:35 p.m. The facility census was 13.
Facility: Kozy Korner I Hannibal, MO 12-Bed Residential Facility Date of Notice: February 2006		Owner: Hannibal Health Resources, Inc. Operator: Same Registered Agent: Kathryn L. Miller	Legal Action: Uncorrected Class II Notice of Noncompliance
Description: At the revisit on 2/3/06, the (omission) failed to correct deficiencies cited at the 12/9/05 annual inspection. The facility failed to ensure a safe and effective medication system. Facility staff failed to administer medications according to physician orders and failed to verify medication orders with the physician before staff administered the medications to a new resident.
Facility: Maple Grove Lodge Louisiana, MO 90 Bed Skilled Nursing Facility Date of Notice: March 2006		Owner: CCC Maple Grove, LLC Operator: Community Care Center of Louisiana, Inc. Registered Agent: James J. Giaroina	Legal Action: Class I Notice of Noncompliance
Description: The facility failed to ensure facility nursing staff provided resident care according to a resident's condition. Resident #14 had undergone a total laryngectomy the previous week and had a tracheostomy when admitted to the facility. The resident could only breathe through the tracheostomy opening. Facility nursing staff reported an inaccurate understanding of the resident's condition, failed to assess and provide needed tracheostomy care to ensure the resident's tracheostomy remained open or report the condition of the resident's tracheostomy site to the physician. The resident developed respiratory distress on 2/5/05 (sic) with subsequent respiratory arrest and cardiac arrest and was transferred to the emergency room with a completely occluded tracheostomy opening. Facility nursing staff failed to communicate to emergency personnel the resident's status as post total laryngectomy so that appropriate emergency procedures could be implemented to open the resident's airway. The emergency room physician said CPR was unsuccessful and the resident expired in the emergency room. The facility census was 65 residents.
Facility: Maple Grove Lodge Louisiana, MO 90-Bed Skilled Nursing Facility Date of Notice: April 2006		Owner: CCC Maple Grove, LLC Operator: Community Care Center of Louisiana, Inc. Registered Agent: James J. Giaroina	Legal Action: Uncorrected Class II Notice of Noncompliance
Description: At the revisit, facility staff failed to provide hygiene and incontinence care to three residents, failed to provide one resident with catheter care, and failed to ensure staff did not use worn and damaged mechanical lift slings to prevent the potential for an accident during transfers of one resident. The facility census was 55 residents.
Facility: Riverdell Care Center Boonville, MO 60-Bed Skilled Nursing Facility Date of Notice: April 2006		Owner: The DCB Real Estate Partnership LP Operator: Boonville #2, Inc. Registered Agent: None	Legal Action: Class I Notice of Noncompliance
Description: The facility failed to provide one resident with sufficient fluid intake to maintain proper hydration and health. The facility staff failed to provide adequate fluids as ordered by the resident's physician to prevent dehydration. The resident was admitted to the hospital on 1/15/06 with diagnoses of pneumonia and dehydration. The resident died on 1/16/06.
Facility: Williams Residential II Hannibal, MO 19-Bed Residential Care Facility Date of Notice: April 2006		Owner: Williams, Harold & Louise Operator: H.R.W., Inc. Registered Agent: Wentric Williams	Legal Action: Class I Notice of Noncompliance
Description: Facility staff knowingly acted and omitted duties, failed to provide supervision and protective oversight and jeopardized the health, safety and welfare of four residents. Three of the residents are under state custody as juveniles. On 4/9/06 at 2:30 a.m., a facility staff person took three residents by facility van to a gang fight involving 20 individuals (facility staff, residents and community members). The fourth resident (under state custody) left separately, running to the fight, was injured and later arrested for assault, property damage and disturbing the peace as a result of participating in the fight. A second staff person on duty at the time stayed at the facility. A third staff person, off duty, also participated in the fight. None of the three staff persons reported the incident to the administrator. The facility census was 19.
Facility: Mark Twain of Huntsville Huntsville, MO 30-Bed Residential Care Facility Date of Notice: May 2006		Owner: Mark Twain Care LLC Operator: Mark Twain Assisted Living, Inc. Registered Agent: Kathryn L. Miller	Legal Action: Class I Notice of Noncompliance
Description: A complaint investigation was completed on 4/20/06 and a Class I citation was issued in the area of Administration and Resident Care. On 3/27/06, a resident (who had a history of hospitalization for pneumonia) developed labored breathing, a fever, fatigue and a change in blood pressure and pulse. On 3/27/06 and 3/28/06, staff sent faxes to the physician regarding the resident's condition but did not get a response until 3/29/06. On 3/29/06, the physician ordered an antibiotic to be given four times a day for seven days. The facility received the antibiotic later on 3/29/06 but staff did not give the resident any of the antibiotic. From 3/27/06 to 3/30/06, staff had not notified the licensed nurse for an assessment of the resident. On 3/30/06 at 7:02 a.m., staff found the resident unresponsive in his/her bed. Emergency personnel were called but were unable to revive the resident. The coroner ruled the cause of death as pneumonia.
Facility: Crosspointe Residential Care Facility, Inc. Edina, MO 47-Bed Residential Care Facility Date of Notice: May 2006		Owner: Crosspointe Residential Care Facility, Inc. Operator: Same Registered Agent: Tony D. Small	Legal Action: Uncorrected Class II Notice of Noncompliance
Description: SLTC staff completed a revisit on 5/10/06 and cited the following violations. The facility census was 41. The facility failed to ensure two individuals were not listed on the employee disqualification list prior to hiring and contact with residents. The facility failed to provide supervision and oversight to one resident who had a history of alcohol abuse before and during admission. The facility failed to notify the physician when the resident was drunk in the facility, aggressive towards staff or when the resident fell and hit his/her head. The administrator also failed to notify the physician before instructing staff to give the resident his/her medication (that had the potential for adverse side effects when mixed with alcohol) or when the resident's behavior escalated after receiving the medication. The facility also failed to have a system to monitor what this resident or other residents brought into the facility after being on pass.
Facility: Schuyler County Nursing Home Queen City, MO 60-Bed Skilled Nursing Facility Date of Notice: May 2006		Owner: Schuyler County Nursing Home Operator: Schuyler County Nursing Home District Registere Agent: Not Listed	Legal Action: Uncorrected Class II Notice of Noncompliance
Description: A revisit was completed on 4/21/06 with the following uncorrected violations: Administration and Resident Care – The facility failed to provide appropriate infection control procedures during and after the use of the blood sugar monitoring devices and during medication administration, failed to document if medication had been administered and failed to administer the correct dose of insulin in accordance with acceptable nursing practice. The facility failed to provide personal care and hygiene services to residents who required extensive or total assistance from staff. The facility failed to have a comprehensive infection control program to monitor and investigate the cause for specific organisms. Facility staff failed to wash their hands or change their gloves after providing personal care as indicated by accepted practice to prevent the spread of infection and the potential for cross-contamination. The facility failed to notify the physician that one resident, who required insulin therapy had high blood glucose levels and had also failed to notify the physician in a timely manner of an insulin medication error. Dietary Requirements – The facility failed to ensure that facility staff offered bedtime snacks on a daily basis.
Facility: Knox County Nursing Home District Edina, MO 60-Bed Skilled Nursing Facility Date of Notice: June 2006		Owner: Knox County Nursing Home Dist. Operator: Same Registered Agent: Not Listed	Legal Action: Uncorrected Class II Notice of Noncompliance
Description: The facility failed to provide attention and nursing care to one resident who fell and hit his head. The facility failed to obtain vital signs when completing neurological assessments that would indicate a potential change in the resident's status.
Facility: North Village Park Moberly, MO 184-Bed Skilled Nursing Facility Date of Notice: July 2006		Owner: MS Associates, LP Operator: North Village Park, LLC Registered Agent: Richard J. Destefane	Legal Action: Class I Notice of Noncompliance
Description: Facility staff failed to ensure one resident (Resident #1), with a history of elopement and suicide attempt, did not leave the facility unattended and without staff knowledge. Staff failed to follow the facility's policy and procedure addressing resident elopement.
Facility: Mark Twain of Huntsville Huntsville, MO 30-Bed Residential Care Facility Date of Notice: July 2006		Owner: Mark Twain Care LLC Operator: Mark Twain Assisting Living, Inc. Registered Agent: Kathryn L. Miller	Legal Action: Uncorrected Class II Notice of Noncompliance
Description: Facility staff failed to ensure one resident (Resident #2), who complained of chest pain, of three sampled residents, received a chemical stress test as ordered. The census was 25.
Facility: Crosspointe Residential Care Facility Inc. Edina, MO 47-Bed Residential Care Facility Date of Notice: August 2006		Owner: Crosspointe Residential Care Facility, Inc. Operator: Same Registered Agent: Tony D. Small	Legal Action: Class I Notice of Noncompliance
Description: The facility staff failed to provide adequate supervision and oversight to one resident with a history of self-inflicted wounds, resulting in the resident self-inflicting multiple wounds on him/herself with razor blades on three separate occasions (6/28/06, 7/8/06 and 7/16/06) and failed to notify the resident's physician of two of the incidents. Also, the facility failed to monitor the whereabouts of the resident. The resident left the facility in a motor vehicle with two individuals and returned to the facility two hours later in a distraught state of mind.
Facility: Fountain Court Care Center Hannibal, MO 38-Bed Skilled Nursing Facility Date of Notice: September 2006		Owner: Rupp, Phyllis King Operator: Leah, Inc. Registered Agent: Phyllis King Rupp	Legal Action: Uncorrected Class II Notice of Noncompliance
Description: Facility staff failed to correct violations including: Facility staff failed to consult with the resident's physician for one resident with the potential for requiring physician intervention or need to alter treatment. Facility staff failed to ensure the results of the most recent deficiencies were available for examination and failed to post the results in a place readily accessible to all residents, families, and visitors. Facility staff failed to provide care in a manner and environment which maintained or enhanced the residents' dignity. Facility staff failed to follow physician orders for two residents. Facility staff failed to consistently document intake and output values for one resident. Facility failed to follow acceptable standards of practice of nursing for gastrostomy feedings for one resident. Facility staff failed to provide care in accordance with the written plan of care for two residents. The facility failed to adequately care plan and implement procedures for one resident who had a swallowing and choking history. Facility staff failed to ensure three residents were repositioned at least every two hours. Facility staff failed to provide care for six residents who needed assistance with personal care received assistance based on their individual need. The facility staff failed to use proper technique when using a mechanical lift and with turning for two residents. Facility staff failed to have an infection control program to prevent the development and transmission of disease and infection in the facility. Facility staff failed to track and investigate infections, which included the type of organism and corrective action. Facility staff failed to ensure proper hand washing after each direct resident contact to prevent cross-contamination for four residents. The facility failed to provide administration in a manner which effectively and efficiently used its resources to attain or maintain each resident's highest practicable physical, mental and psychosocial well-being. The facility failed to ensure certified nurse aides were able to demonstrate proficiency in skills and techniques necessary to care for residents as follows: by not promoting dignity, not assisting residents with personal grooming, not providing adequate supervision, not following care plans, not respositioning residents at least every 2 hours, not releasing physical restraints at least every two hours and not properly washing hands. New violations included: Facility staff failed to assess and care plan the need for a restraint for one resident and failed to reassess the continued need for one resident's restraint. Facility staff failed to complete a significant change Minimum Data Set (MDS) assessment within 14 days after a significant change for one resident. Facility staff failed to ensure two residents with decreased range of motion received the appropriate care and services to prevent decline.
Facility: Bristol Manor of Palmyra Palmyra, MO 12-Bed Residential Care Facility Date of Notice: October 2006		Owner: Not Listed Operator: Bristol Care, Inc. Registered Agent: David C. Furnell	Legal Action: Uncorrected Class II Notice of Noncompliance
Description: At the revisit, the facility failed to have a safe and effective system of medication control and use, failed to ensure physician orders were followed and failed to keep a daily record of medications administered to residents on a daily basis. The facility census was eight residents.
Facility: The Living Center Marshall, MO 99-Bed Skilled Nursing Facility Date of Notice: October 2006		Owner: Fitzgibbon Health Services Operator: Not Listed Registered Agent: Fitzgibbon Health Services	Legal Action: Uncorrected Class II Notice of Noncompliance
Description: A survey was completed on 8/10/06. The facility was not in compliance with participation requirements. A revisit was completed in 9/28/06. The facility staff failed to: obtain an advanced directive for one resident who staff documented had a living will; conduct an assessment of one resident following a significant declining change in the resident's physical and mental condition; provide effective pain management for one resident to properly store supplements and ensure drinks and food were covered during storage; provide appropriate peri care to three incontinent residents; properly store supplements and ensure drinks and food were covered during storage.
Facility: Country Aire Estates Hannibal, MO 16-Bed Residential Care Facility Date of Notice: November 2006		Owner: Noland, Georgia Mae Operator: Georgia Mae Noland Registered Agent: Georgia Mae Noland	Legal Action: Uncorrected Class II Notice of Noncompliance
Description: At the revisit, the facility failed to ensure that each floor was separated by construction of at least a one (1)-fire resistant rating. The floor under the first floor west entry corridor and west side of the building was unprotected.
Facility: Omega House Hannibal, MO 10-Bed Residential Care Facility Date of Notice: November 2006		Owner: Not Listed Operator: Sandra Ghattas Registered Agent: Jeffrey R. Curl	Legal Action: Class I Notice of Noncompliance
Description: The facility failed to provide protective oversight of one resident (Resident #1) with a recent history of suicide attempts. The facility failed to administer medication to treat the resident's manic symptoms as ordered by the physician, failed to supervise the resident and did not know when the resident signed out on leave on 9/30/06 and 10/19/06, did not know where the resident was going, did not take measures to locate the resident when he/she did not return to the facility and failed to notify the resident's physician. On 10/19/06, staff did not know the resident had signed out at 7:30 a.m., did not attempt to look for Resident #1 when he/she had not returned at 9:00 a.m. and did not notify the physician. At 12:00 p.m., facility staff heard on the television that Resident #1 had stepped into the path of a truck at 9:30 a.m. and was killed. The facility census was 9.
Facility: Fountain Court Care Center Hannibal, MO 38-Bed Nursing Facility Date of Notice: November 2006		Owner: Rupp, Phyllis King Operator: Phyllis King Rupp Registered Agent: Phyllis King Rupp	Legal Action: Uncorrected Class II Notice of Noncompliance
Description: Facility staff failed to provide care in a manner and environment which maintained or enhanced residents' dignity. The facility failed to provide services to meet professional standards of quality: physician ordered treatment. The facility failed to ensure residents were repositioned. The facility failed to provide care for residents: assistance with incontinency care and toileting. The facility failed to ensure residents received adequate supervision and assistance to prevent accidents: mechanical lift procedures, locking wheelchair brakes, and personal or chair alarm.
Facility: Bristol Manor of Maryville Maryville, MO 12-Bed Residential Care Facility Date of Notice: December 2006		Owner: Not Listed Operator: Bristol Care, Inc. Registered Agent: David C. Furnell	Legal Action: Class I Notice of Noncompliance
Description: The facility failed to have a minimum of one qualified employee on duty at all times to provide oversight and fire safety for nine residents. The manager left the building for at least 30 minutes and no other staff was on duty. Six residents expressed anxiety and fear.
Facility: Shinn Residential Center I Hannibal, MO 9-Bed Residential Care Facility Date of Notice: December 2006		Owner: Shinn Residential Center, Inc. Operator: Same Registered Agent: Gary Shinn	Legal Action: Class I Notice of Noncompliance
Description: The facility failed to provide proper care to meet the needs of one resident who was found in respiratory distress laboring to breathe after eating a donut at breakfast. Facility staff failed to immediately contact emergency medical services before contacting another staff member at his/her home to relay the events. Also, staff failed to intervene to ascertain if the resident had an occluded airway or perform the Heimlich maneuver. When ambulance personnel arrived the resident was in cardiac arrest. The resident was hospitalized and subsequently died with cause of death noted as cardiopulmonary arrest due to aspiration.

NORTHWEST REGION
Facility: Apple Ridge Care Center Waverly, MO 60-Bed Skilled Nursing Facility Date of Notice: February 2006	Owner: Riverview Heights Company Operator: Waverly #1 Inc. Registered Agent: Lonnie G. Hasty		Legal Action: Uncorrected Class II Notice of Noncompliance
Description: At the revisit on 1/19/06, the facility had uncorrected deficiencies in the area of Administration and Resident care. The facility failed to keep one wing of the facility odor free, failed to provide appropriate incontinence care to two residents and failed to provide adequate supervision for one resident identified with a behavior of ingesting non-edible objects, to prevent the resident drinking perineal cleanser.
Facility: Cameron Manor Cameron, MO 120-Bed Skilled Nursing Facility Date of Notice: February 2006	Owner: J&R Associates, LP Operator: Same Registered Agent: Edward C. Clausen		Legal Action: Class I Notice of Noncompliance
Description: The facility failed to serve one resident's diet as ordered by the resident's physician. Facility staff failed to correctly transcribe the complete diet order change from the resident's physician order sheet to the resident's tray card resulting in the resident being served a regular hotdog instead of the ordered pureed hotdog. The resident choked on the hotdog and later expired at the hospital.
Facility: Valley Manor & Rehab Center Excelsior Springs, MO 120-Bed Skilled Nursing Facility Date of Notice: February 2006		Owner: Not Listed Operator: Excelsior Springs #1, Inc. Registered Agent: Not Listed	Legal Action: Uncorrected Class II Notice of Noncompliance
Description: The facility staff failed to provide residents with meals served at palatable temperatures and failed to maintain steam table foods above 140 degrees Fahrenheit. Staff also failed to wash their hands when switching between raw foods and ready-to-eat foods.
Facility: The Baptist Home Chillicothe Chillicothe, MO 34 Bed Intermediate Care Facility Date of Notice: March 2006		Owner: The Baptist Home Chillicothe Operator: Same Registered Agent: Steven R. Jones	Legal Action: Class I Notice of Noncompliance
Description: The facility failed to ensure one confused resident, with a history of elopements did not exit the building without staff knowledge. On 2/20/06 at approximately 3:30 a.m., local police found Resident #1 at the intersection of Highway 65 and new Highway 190. The resident was walking south pushing a wheelchair in the middle of a four lane highway about one quarter of a mile from the facility.
Facility: Carriage Square RCF St. Joseph, MO 32 Bed Residential Care Facility Date of Notice: March 2006		Owner: Carriage Square Health Care Center, Inc. Operator: Same Registered Agent: William Burford	Legal Action: Class I Notice of Noncompliance
Description: The facility failed to provide protective oversight for one resident (Resident #1), who had a guardian and was a high risk for elopement. The resident eloped on 2/19/06 and staff were unaware the resident was out of the facility. At approximately 11:30 p.m., a community member witnessed Resident #1 walking with a walker in a highly traveled area across a bridge with no sidewalks or area to get out of the way of oncoming traffic.
Facility: Quail Run Health Care Center Cameron, MO 84 Bed Skilled Nursing Facility Date of Notice: March 2006		Owner: DCB Real Estate Partnership LP Operator: Cameron #1, Inc. Registered Agent: Lonnie G. Hasty	Legal Action: Uncorrected Class II Notice of Noncompliance
Description: Based on a revisit completed on 3/17/06, the facility failed to ensure residents who were restrained were provided the opportunity for exercise for 10 minutes every two hours. The facility failed to ensure proper procedure for the placement checking of g-tubes and failed to clarify a supplement order for a resident with a history of weight loss. The facility failed to provide timely nursing care for a resident who complained of blood in his/her urine and failed to appropriately assess and treat mouth pain for one resident with broken, decayed teeth. The facility failed to ensure residents were transferred appropriately using gait belts to prevent accidents. The facility had a medication error rate of 6%. Facility staff failed to maintain a sanitary infection control system.
Facility: Abbey Woods St. Joseph, MO 100-Bed Skilled Nursing Facility Date of Notice: April 2006		Owner: Not Listed Operator: Heritage Healthcare Holdings, Inc. Registered Agent: Lowell Fox	Legal Action: Class I Notice of Noncompliance
Description: The facility failed to ensure each resident receives adequate supervision when one confused resident, with a history of wandering, left the facility without staff knowledge. On 3/26/06 at approximately 6:50 a.m., the resident left the facility and walked 3.5 miles, while crossing an interstate highway and two four-lane highways, to a family member's home. The facility did not know the resident had left until the family member contacted the facility at 7:50 a.m. The temperature was 30 degrees Fahrenheit and the resident wore only a sweater over his/her clothing.
Facility: Nodaway Nursing Home Maryville, MO 60-Bed Skilled Nursing Facility Date of Notice: April 2006		Owner: Nodaway County Commission Operator: Tiffany Care Centers, Inc. Registered Agent: David Duncan	Legal Action: Uncorrected Class II Notice of Noncompliance
Description: A survey was completed on 2/15/06. The facility was not in substantial compliance with participation requirements. A revisit was completed on 4/12/06. The facility staff failed to assess the condition of one resident's skin that was at high risk for pressure sores.
Facility: Valley Manor Rehabilitation Center Excelsior Springs, MO 120 Bed Skilled Nursing Facility Date of Notice: April 2006		Owner: Not Listed Operator: Excelsior Springs #1 Inc. Registered Agent: None	Legal Action: Class I Notice of Noncompliance
Description: The facility failed to provide the necessary care and services to maintain the highest practicable physical, mental and psychosocial well-being. On 3/21/06 facility staff failed to initiate cardiopulmonary resuscitation (CPR) for one resident when the resident ceased to have vital signs.
Facility: Quail Run Health Care Center Cameron, MO 84-Bed Skilled Nursing Facility Date of Notice: April 2006		Owner: The DCB Real Estate Partnership LP Operator: Cameron #1, Inc. Registered Agent: Lonnie G. Hasty	Legal Action: Uncorrected Class II Notice of Noncompliance
Description: A survey was completed on 1/17/06 and revisits were completed on 3/17/06 and 4/14/06. The facility was not in substantial compliance with participation requirements. The facility staff failed to date opened insulin vials and discard the vials after 28 days for three residents, failed to carry forward physician's orders for oxygen on the monthly physician order sheets and failed to obtain a physician's order for medications to be administered prior to a cardiac contrast study.
Facility: Lawson Manor & Rehab Lawson, MO 60-Bed Skilled Nursing Facility Date of Notice: May 2006		Owner: Not Listed Operator: Lawson #1, Inc. Registered Agent: Not Listed	Legal Action: Uncorrected Class II Notice of Noncompliance
Description: A survey was completed on 3/10/06. The facility was not in substantial compliance with participation requirements. A revisit was completed on 4/27/06. The facility failed to develop and implement policy and procedures for alleged abuse to the state agency. On 4/8/06 the director of nurses reported to the administrator that a certified nurse aide smacked a resident on the mouth. The facility policy and procedure failed to address Missouri requirements and timeframes for reporting alleged abuse. Facility staff failed to assure nursing staff did not re-label physician ordered medications for two residents, obtain physician ordered laboratory tests for one resident and ensure two licensed staff destroyed medications. Also, the facility failed to assess, identify and implement interventions to ensure one resident received appropriate treatment for aggressive behaviors that threatened to harm the resident or others.
Facility: La Verna Village Nursing Home, Inc. Savannah, MO 120-Bed Skilled Nursing Facility Date of Notice: May 2006		Owner: Sisters of St. Francis Operator: La Verna Village NH, Inc. Registered Agent: Sister Kathleen Reichert	Legal Action: Uncorrected Class II Notice of Noncompliance
Description: A survey was completed on 3/7/06. The facility was not in substantial compliance with participation requirements. A revisit was completed on 5/2/06. The facility staff failed to provide an ongoing activity program to meet the needs of the twelve residents residing in the SCU. Facility staff failed to update five residents' plan of care to address the residents' current care needs. Staff failed to prevent one resident, with a history of pressure sores from developing a new pressure sore and provide interventions and treatment to promote healing. In addition, the facility failed to prevent catheter drainage bags and tubing from touching the floor to prevent possible infections.
Facility: Saxton Riverside Care Center St. Joseph, MO 90-Bed Intermediate Care Facility Date of Notice: May 2006		Owner: Saxtons, Inc. Operator: Senior Life, Inc. Registered Agent: Glen Muir	Legal Action: Uncorrected Class II Notice of Noncompliance
Description: A survey was completed on 3/17/06. The facility was not in substantial compliance with participation requirements. A revisit was completed on 5/17/06. The facility staff failed to assess one resident MRSA status and potential for spreading MRSA prior to institution isolation procedures that affected the resident's qualify of life through involuntary seclusion. The facility staff has continued isolation procedures for more than 12 months without validating the resident's actual MRSA status or attempt to use less restrictive alternatives in accordance with infection control practices.
Facility: Sunnyview Nursing Home & Apartments Trenton, MO 154-Bed Skilled Nursing Facility Date of Notice: July 2006		Owner: Grundy County Nursing Home District Operator: Grundy County Nursing Home District Registered Agent: Not Listed	Legal Action: Uncorrected Class II Notice of Noncompliance
Description: The facility failed to ensure staff maintained a medication error rate of less than five percent. Facility staff made four medication errors out of 42 opportunities for error, affecting one of 11 sampled residents and two additional residents resulting in an error rate of 9.5%.
Facility: Superior Park Assisted Living Excelsior Springs, MO 66-Bed Residential Care Facility Date of Notice: July 2006		Owner: DST, Inc. Operator: DST, Inc. Registered Agent: Thomas A. Walker	Legal Action: Uncorrected Class II Notice of Noncompliance
Description: The facility failed to provide documentation that showed they used the funds of individual residents exclusively for the resident. The facility failed to provide all written accounts of the residents' funds. This information was not available for each resident and his/her designee or legal guardian on a quarterly basis.
Facility: Pine View Manor, Inc. Stanberry, MO 70-Bed Skilled Nursing Facility Date of Notice: July 2006		Owner: Pine View Manor, Inc. Operator: Same Registered Agent: Karl Frederick	Legal Action: Uncorrected Class II Notice of Noncompliance
Description: The facility failed to revise one resident's care plan when the resident developed an open wound on the bottom of the left foot. The facility failed to assure staff followed physician's orders for obtaining weekly weights for one resident. The facility failed to follow the facility's policy and acceptable practice for checking placement of a feeding tube for one resident before administering medication and feeding solution. The facility failed to inform one resident's physician of an open area on the bottom of the resident's left foot and failed to follow a physician's treatment order for a dressing and substituted a different dressing without notifying the physician. The facility failed to provide appropriate perineal care following incontinence episodes and appropriate catheter care to prevent the potential development of urinary tract infections for two residents who were at risk for developing an infection. The facility failed to assure staff maintained a medication error rate of less than five percent. Facility staff made four medication errors out of 40 opportunities for errors. This resulted in a medication error rate of 7-1/2%. The facility failed to assure staff washed their hands when going from dirty to clean tasks.
Facility: Lawson Manor & Rehab Lawson, MO 60-Bed Skilled Nursing Facility Date of Notice: July 2006		Owner: Not Listed Operator: Lawson #1, Inc. Registered Agent: Not Listed	Legal Action: Class I Notice of Noncompliance
Description: The facility staff failed to immediately notify one resident's physician when there was a significant change in the resident's condition and need to alter treatment to maintain the highest practicable physical, mental and psychosocial well being. On 6/16/06, the resident's family members reported to facility staff that the resident complained of numbness in the right hand and arm and had difficulty swallowing. The family members requested facility staff report the resident's symptoms to the resident's physician from 6/16/06 to 6/18/06. Facility staff faxed the resident's physician's office but did not call or page the physician to inform him/her of the change in condition. Also, facility staff failed to obtain vital signs and failed to conduct ongoing assessments of the resident's condition for two and one half days. The resident was admitted to the hospital on 6/19/06 and died on 6/23/06 due to a massive stroke.
Facility: Northview Manor Tarkio, MO 95-Bed Skilled Nursing Facility Date of Notice: July 2006		Owner: SPTIHS Properties Trust Operator: Five Star Quality Care-MO, LLC Registered Agent: CSC-Lawyers Incorporating Service Company	Legal Action: Uncorrected Class II Notice of Noncompliance
Description: The facility failed to ensure staff followed acceptable standards of practice when staff failed to notify the physician of an elevated blood pressure for one resident. The facility failed to ensure staff provided care for two residents with urinary catheters in a manner to prevent infection. The facility failed to ensure staff used techniques that reduced the possibility of injury during transfers for five residents. The facility failed to ensure staff maintained a medication error rate of less than five percent. Facility staff made six medications errors out of 43 opportunities for errors, affecting five residents. This resulted in a medication error rate of 13.95%.
Facility: Eastview Manor Care Center Trenton, MO 90-Bed Skilled Nursing Facility Date of Notice: August 2006		Owner: Eastview Manor, Inc. Operator: Eastview Manor, Inc. Registered Agent: Clyde L. Taff	Legal Action: Uncorrected Class II Notice of Noncompliance
Description: The facility failed to ensure staff provided care for two residents with urinary catheters in a manner to prevent a urinary tract infection.
Facility: Pine View Manor, Inc. Stanberry, MO 70-Bed Skilled Nursing Facility Date of Notice: August 2006		Owner: Pine View Manor, Inc. Operator: Pine View Manor, Inc. Registered Agent: Karl Frederick	Legal Action: Uncorrected Class II Notice of Noncompliance
Description: The facility failed to revise one resident's care plan when the resident developed an open wound on the bottom of the left foot. The facility failed to assure staff followed physician's orders for obtaining weekly weights for one resident. The facility failed to follow the facility's policy and acceptable practice for checking placement of a feeding tube for one resident before administering medication and feeding solution. The facility failed to inform one resident's physician of an open area on the bottom of the resident's left foot and failed to follow a physician's treatment order for a dressing and substituted a different dressing without notifying the physician. The facility failed to follow appropriate perineal care following incontinence episodes and appropriate catheter care to prevent the potential development of urinary tract infections for two residents who were at risk for developing an infection. The facility failed to assure staff maintained a medication error rate of less than five percent. Facility staff made three medication errors out of 40 opportunities for errors. This resulted in a medication error rate of 7-1/2%. The facility failed to assure staff washed their hands when going from dirty to clean tasks.
Facility: Pine View Manor, Inc. Stanberry, MO 70-Bed Skilled Nursing Facility Date of Notice: August 2006		Owner: Pine View Manor, Inc. Operator: Same Registered Agent: Karl Frederick	Legal Action: Uncorrected Class II Notice of Noncompliance
Description: The facility failed to prevent pressure sores, failed to provide pressure relief to promote healing for two residents and failed to follow physician's orders for one resident. The facility failed to provide appropriate perineal care following incontinence episodes and appropriate catheter care to prevent injury and the potential development of urinary tract infections for two residents who were at risk for developing an infection. The facility failed to ensure staff maintained a medication error rate of less than five percent. Facility staff made three medication errors out of 40 opportunities for errors, affecting two residents and resulted in a medication error rate of 7.5%. The facility failed to ensure staff washed their hands when going from dirty to clean tasks. This practice affected two residents.
Facility: Royal Care Center, Inc. Excelsior Springs, MO 108-Bed Skilled Nursing Facility Date of Notice: September 2006		Owner: Royal Care Center, Inc. Operator: Same Registered Agent: Jesse J. Hwang	Legal Action: Class I Notice of Noncompliance
Description: The facility failed to assess the need for a restraint and re-assess for the continued need for the restraint for one resident. The facility identified nine residents with restraints. The facility failed to ensure staff cared for one resident in a manner that promoted enhancement of the resident's quality of life. The facility failed to ensure staff followed standards of practice for suctioning one resident, failed to ensure residents' medication labels matched the physicians' orders for two residents, failed to ensure staff followed a physician's medication order for one resident, and failed to ensure staff obtained a lab test as ordered for one resident. The facility failed to ensure staff followed the care plan to monitor lab values and toilet residents every two hours, apply skin protectant for one resident, and observe food likes and dislikes for one resident. The facility failed to ensure staff adequately investigated the cause of and tried different treatments for redness and excoriation of the buttocks which had continued for approximately four months for one resident. The facility failed to ensure staff provided incontinence care for two residents and provide adequate incontinence care, and trimmed fingernails for one resident who scratched his/her face. The facility failed to provide perineal and catheter care to prevent urinary tract infections for six residents. The facility failed to provide treatment and services to prevent further decrease in range of motion for one resident and failed to provide restorative therapy as ordered for four additional residents. The facility failed to maintain a safe environment when staff continued to keep available for use mechanical lifts with torn, frayed slings and used a mechanical lift that did not operate properly. The facility failed to ensure staff used techniques to reduce the possibility of injury during transfer for residents. The facility failed to have an alternate power source available to provide suction for one resident who had a tracheotomy and required suctioning. The facility failed to ensure staff maintained a medication error rate of less than five percent. Facility staff made six medication errors out of 42 opportunities for errors. The medication error rate was 14.28%. The facility failed to ensure adequate staffing to meet resident needs. The facility failed to ensure staff practiced infection control measures when one staff provided pericare and placed the soiled washcloths on the sheepskin covering over the bedrail and when a second staff walked down a carpeted hall with fecal material on his/her shoe. The facility failed to ensure staff washed hands between soiled and clean tasks. The facility failed to take preventive measures to eliminate the presence of mice, roaches and flies in the kitchen, dining room, and in resident rooms. The administration failed to provide adequate resources and services to maintain each residents' highest level of physical, psychosocial and mental well-being.
Facility: Saxton Woods Care Center St. Joseph, MO 240-Bed Skilled Nursing Facility Date of Notice: September 2006		Owner: Saxton's TLC, Inc. Operator: Caring for Seniors, Inc. Registered Agent: Glen Muir	Legal Action: Uncorrected Class II Notice of Noncompliance
Description: The facility failed to maintain an effective infection control program to monitor and track residents after the facility had an outbreak of lice. The facility identified fifteen residents and five staff members treated for lice.
Facility: Crestview Home, Inc. Bethany, MO 160-Bed ICF Date of Notice: October 2006		Owner: Harrison County Operator: Crestview Home, Inc. Registered Agent: Jeanie Price	Legal Action: Uncorrected Class II Notice of Noncompliance
Description: The facility failed to maintain a complete fire alarm system. The facility failed to initially assess the need for a restraint. The facility failed to provide care in a manner to reduce the possibility of urinary tract infections. The facility failed to assure staff used techniques to reduce the possibility of injury during transfers.
Facility: Hillcrest Manor Hamilton, MO 90-Bed Skilled Nursing Facility Date of Notice: November 2006		Owner: DCB Real Estate Partnership LLC Operator: Hamilton #1, Inc. Registered Agent: Mary H. Perry	Legal Action: Uncorrected Class II Notice of Noncompliance
Description: A survey was completed on 9/14/06. The facility was not in compliance with participation requirements. On 11/14/06 a revisit was completed. The facility staff failed to maintain the kitchen range hood enclosure in compliance with standards of the National Fire Protection Association 96 and the 2000 (Existing) Life Safety Code.
Facility: Oak Grove Nursing & Rehab Oak Grove, MO 90-Bed Skilled Nursing Facility Date of Notice: December 2006		Owner: Grove-Oak-Cal Assoc., LLP Operator: N & R of Oak Grove, LLC Registered Agent: Charlotte Stutts	Legal Action: Uncorrected Class II Notice of Noncompliance
Description: At the revisit completed on 11/30/06, facility staff failed to: Properly document and monitor the pulse of a resident who was taking a medication that required pulse monitoring prior to administration and failed to follow-up and notify the physician of abnormal laboratory results for one resident. Provide proper perineal care (cleaning of the genital area) for a resident with an indwelling urinary catheter (a sterile tube inserted into the bladder to drain urine) in a way to prevent any further urinary tract infections (UTIs) or potential for further UTIs for one resident with a history of UTIs. Implement measures to prevent a fall for one resident with limited mobility that resulted in a fall with a head injury; and failed to implement appropriate and timely interventions to address and prevent falls, failed to follow their own facility fall protocol and failed to ensure the resident's bed rail was in proper working order to prevent falls for one resident.
Facility: Crestview Home, Inc. Bethany, MO 160-Bed Nursing Facility Date of Notice: December 2006		Owner: Harrison County, MO Operator: Crestview Home, Inc. Registered Agent: Jeanie Price	Legal Action: Class I Notice of Noncompliance
Description: Facility staff failed to provide supervision to prevent one resident (Resident #1) from eloping. Resident #1 experienced a change in behavior and made statements to staff about wanting to leave the facility. Facility staff were unaware the resident had left the building until they were notified by police that the resident had been found on a gravel road near the facility.
Facility: Shady Lawn Nursing Home Savannah, MO 88-Bed Skilled Nursing Facility Date of Notice: December 2006		Owner: Andrew County Nursing Home District Operator: The Progressive Health Care Group, Inc. Registered Agent: James Lincoln	Legal Action: Uncorrected Class II Notice of Noncompliance
Description: The facility failed to assure staff kept catheter drainage bags below the level of the resident's bladder, keep the catheter tubing off of the floor and failed to anchor the drainage tube to reduce the possibility of urinary tract infections and dislodging of the catheter placement. The facility failed to maintain a medication error rate of less than five percent. Observation showed three errors out of forty opportunities for error, which resulted in a medication error rate of 7.5%.

SOUTHEAST REGION
Facility: Country Meadows Park Hills, MO 66-Bed Skilled Nursing Facility Date of Notice: March 2006	Owner: Park Hills Nursing Center, Inc. Operator: Country Meadows Nursing Center, LLC Registered Agent: Sharo Shirshekan	Legal Action: Class I Notice of Noncompliance
Description: The facility staff failed to provide proper pressure sore care to promote healing and prevent further breakdown for residents with pressure sores. One resident with a Stage IV pressure sore was not adequately assessed, repositioned, care planned and kept clean and dry.
Facility: NHC Healthcare-Desloge Desloge, MO 120-Bed Skilled Nursing Facility Date of Notice: April 2006	Owner: Nat'l. Health Investors, Inc. Operator: NHC Healthcare/Desloge, LLC Registered Agent: Richard F. Laroche, Jr.	Legal Action: Uncorrected Class II Notice of Noncompliance
Description: A survey was completed on 1/26/06. The facility was not in substantial compliance with participation requirements. A revisit was completed on 3/23/06. The facility staff failed to administer tube feedings as directed by physician's orders for five residents.
Facility: L&J Residential Care Farmington, MO 10-Bed Residential Care Facility Date of Notice: June 2006	Owner: Nolting, David L. & Frances J. Operator: L&J Residential LLC Registered Agent: David L. Nolting	Legal Action: Class I Notice of Noncompliance
Description: A licensure inspection was completed on 6/07/06. The facility was not in substantial compliance with participation requirements. The facility staff failed to maintain water temperatures below 120 degrees Fahrenheit in one resident bathroom, which is used by residents in the RCF II. On 5/25/06, the water temperature in the North Hall bathroom measured 137.5 degrees. The maintenance staff drained the hot water heater and adjusted the water temperature. On 5/26/06, the same bathroom sink water measured 164 degrees.
Facility: Bertrand Retirement Home Bertrand, MO 60-Bed Skilled Nursing Facility Date of Notice: July 2006	Owner: Bertrand Retirement Home, Inc. Operator: N&R of Bertrand, Inc. Registered Agent: Charlotte Stutts	Legal Action: Class I Notice of Noncompliance
Description: The facility failed to assess, monitor, and provide interventions for two residents with choking incidents. The first resident choked on food on three separate occasions and required the Heimlich maneuver to clear his/her airway on two of those occasions. The facility failed to implement measures to address the resident's choking risk and the resident continued to eat unsupervised in his/her room. Facility staff identified the second resident at risk for choking and aspiration due to difficulty swallowing. Staff did not implement speech therapy interventions for the resident and the resident experienced choking episodes during meals. The facility census was 45.
Facility: Riverview at the Park Care & Rehab Center Ste. Genevieve, MO 120-Bed Skilled Nursing Facility Date of Notice: August 2006	Owner: Not Listed Operator: Ste. Genevieve County Memorial Hospital Registered Agent: Not Listed	Legal Action: Uncorrected Class II Notice of Noncompliance
Description: The facility failed to provide adequate supervision and assistive devices to prevent an accident for one resident. The facility failed to provide therapeutic diets for two residents at nutritional risk and/or at risk of aspiration. The facility failed to store, prepare and distribute foods under sanitary conditions increasing the risk of cross-contamination and food-borne illness.
Facility: Country Haven Boarding Home – Bldg. II Ste. Genevieve, MO 18-Bed Residential Care Facility Date of Notice: December 2006	Owner: Chaudhry LLC Operator: Osman, LLC Registered Agent: Bilkiss Chaudhry	Legal Action: Class I Notice of Noncompliance
Description: The facility failed to comply with Fire Safety requirements as: The facility failed to implement an approved fire watch when the facility's fire alarm system was out of service for more than four hours. The facility failed to notify the Department of Health and Senior Services when the facility lost power and the fire alarm system was out of service for more than four hours. The facility failed to comply with Administration and Resident Care requirements as the facility failed to provide proper care to meet the residents' needs after the facility lost electrical power for at least 48 hours. The facility census was 13 residents.
Facility: Country Haven Boarding Home – Bldg. I Ste. Genevieve, MO 18-Bed Residential Care Facility Date of Notice: December 2006	Owner: Chaudhry LLC Operator: Osman, LLC Registered Agent: Bilkiss Chaudhry	Legal Action: Class I Notice of Noncompliance
Description: The facility failed to comply with Fire Safety requirements as: The facility failed to implement an approved fire watch when the facility's fire alarm system was out of service for more than four hours. The facility failed to notify the Department of Health and Senior Services when the facility lost power and the fire alarm system was out of service for more than four hours. The facility failed to comply with Administration and Resident Care requirements as the facility failed to provide proper care to meet the residents' needs after the facility lost electrical power for at least 48 hours. The facility census was 17 residents.

SOUTHWEST REGION

Facility: El Dorado Rest Haven

El Dorado Springs, MO

60 Bed Residential Care Facility

Date of Notice: March 2006

Owner: Curry, James & 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 correct the following deficiencies: Two emergency lights failed to work when tested; Staff failed to document one resident's blood sugar checks and insulin administration.

Facility: Anderson Guest House

Anderson, MO

37-Bed Residential Care Facility

Date of Notice: August 2006

Owner: Dupont, Robert and Laverne

Operator: Joplin River of Life Ministries, Inc.

Registered Agent: Charles Churchwell

Legal Action: Class I Notice of Noncompliance

Description: Facility staff failed to maintain comfortable and safe temperatures inside the facility during the time a local, excessive heat warning had been issued by the National Weather Service. The facility census was 30.

Facility: Bristol Manor of Carthage

Carthage, MO

12-Bed Residential Care Facility

Date of Notice: August 2006

Owner: Bristol Care, Inc.

Operator: Same

Registered Agent: David C. Furnell

Legal Action: Class I Notice of Noncompliance

Description: The facility failed to provide 24-hour protective oversight for nine residents. The facility manager left the facility and did not return. As a result, the facility was left unattended for an extended period of time.

Facility: Springfield Skilled Care Center

Springfield, MO

104-Bed Skilled Nursing Facility

Date of Notice: September 2006

Owner: Not Listed

Operator: Springfield Residential Center, Inc.

Registered Agent: Thomas Kenny

Legal Action: Class I Notice of Noncompliance

Description: Facility staff failed to assess and notify the physician of a change in condition for one resident (Resident #1). Resident #1 experienced a significant change in condition beginning 7/22/06. Facility staff failed to notify the physician until 7/24/06 at 11:30 a.m. when they left a voice mail. Staff found the resident unresponsive at 11:42 a.m. and at 11:51 a.m., the paramedics arrived and pronounced the resident's death at that time.

Facility: Manorcare Health Services

Springfield, MO

40-Bed Skilled Nursing Facility

Date of Notice: September 2006

Owner: Manorcare Health Services

Operator: Same

Registered Agent: CT Corporation System

Legal Action: Class I Notice of Noncompliance

Description: Facility staff failed to administer intravenous fluids according to the physicians' orders for two residents (Resident #1 and #2) with one resident requiring hospitalization.

Facility: Appleton City Manor

Appleton City, MO

60-Bed Intermediate Care Facility

Date of Notice: November 2006

Owner: Appleton City Manor LLC

Operator: Same

Registered Agent: Marcus G. Reed

Legal Action: Class I Notice of Noncompliance

Description: The facility failed to assess, develop and implement interventions for the use of side rails after one resident had a stroke. On 8/4/06 staff found the resident wedged between the mattress and the side rail. On 9/2/06, staff found the resident trapped at the waist between the mattress and the right side rail. Staff did not implement any measures to prevent potential more serious incidents until 10/31/06. The facility census was 51 residents.

Facility: Carl Junction Guest House

Carl Junction, MO

18-Bed Residential Care Facility

Date of Notice: December 2006

Owner DuPont, Robert & Laverne

Operator: Joplin River of Life Ministries, Inc.

Registered Agent: Charles Churchwell

Legal Action: REVOCATION OF LICENSURE

License to be null and void at the close of January 5, 2007

Facility: Guest House III

Joplin, MO

20-Bed Assisted Living Facility

Date of Notice: December 2006

Owner: Dupont, Robert & Laverne

Operator: Joplin River of Life Ministries, Inc.

Registered Agent: Charles Churchwell

Legal Action: DENIAL OF LICENSURE

Temporary operating permit extended to January 5, 2007 to allow for an orderly transfer of residents from the facility.

Facility: Guest House

Joplin, MO

27-Bed Assisted Living Facility

Date of Notice: December 2006

Owner: Dupont, Robert & Laverne

Operator: Joplin River of Life Ministries, Inc.

Registered Agent: Charles Churchwell

Legal Action: DENIAL OF LICENSURE

Temporary operating permit extended to January 5, 2007 to allow for an orderly transfer of residents from the facility.

Facility: Anderson Guest House

Anderson, MO

37-Bed Assisted Living Facility

Date of Notice: December 2006

Owner: Dupont, Robert & Laverne

Operator: Joplin River of Life Ministries, Inc.

Registered Agent: Charles Churchwell

Legal Action: DENIAL OF LICENSURE

Temporary operating permit to be null and void at the close of January 5, 2007.

ST. LOUIS REGION
Facility: Page Manor St. Louis, MO 45-Bed Residential Care Facility Date of Notice: January 2006	Owner: Malik Home, LLC Operator: Malik Home, LLC Registered Agent: Saleh Malik		Legal Action: Uncorrected Class II Notice of Non-compliance
Description: The facility failed to correct the following deficiencies: Fire extinguishers were not maintained. Smoke barrier doors separating floors did not close properly. Smoke barrier doors were held open with unapproved devices. Sprinkler heads were not maintained in accordance with NFPA 13. Residents who smoke were not adequately supervised. Resident rooms and other resident use areas were not clean and well maintained. Furniture and equipment were not clean and in good repair. Adequate storage was not provided for resident belongings. The operator did not ensure compliance with regulations. The contact information for each resident's physician was not obtained and kept in the residents' records. Employees did not wear identification badges while working. Employee records were not maintained as required. The facility did not employ a licensed nurse for the required number of hours. Residents' physicians were not notified of laboratory results. The facility staff failed to administer medications without error. Effective measures were not taken to prevent the infestation of rodents. Openings into the building were not protected from the entrance of rodents. Food was not handled in a manner to prevent contamination. Non-food contact services in the kitchen were not maintained in clean condition. Food contact surfaces in the kitchen were not maintained in clean condition.
Facility: Autumn Ridge Herculaneum, MO 69-Bed Residential Care Facility Date of Notice: February 2006		Owner: MLD Delaware Trust Operator: Emeritus Corporation Registered Agent: CT Corporation System	Legal Action: Uncorrected Class II Notice of Noncompliance
Description: The facility failed to correct the following deficiencies: The facility housed residents who required walkers for ambulation on a wing where the nearest exit required residents to negotiate stairs to exit to grade.
Facility: Northgate Park Nursing Home Florissant, MO 156-Bed Skilled Nursing Facility Date of Notice: February 2006		Owner: Not Listed Operator: Prime Care Six, LLC Registered Agent: LexisNexis Document Solutions Inc.	Legal Action: Class I Notice of Noncompliance
Description: The facility staff failed to provide suctioning and oxygen for a resident in respiratory distress. The staff did not have emergency equipment readily available and did not obtain prompt emergency medical care for the resident. When paramedics arrived at the facility, the resident's mouth and lungs were full of secretions and the resident died in the emergency room within one hour of arrival.
Facility: The Riverview St. Louis, MO 120-Bed Skilled Nursing Facility Date of Notice: February 2006		Owner: Not Listed Operator: KJD Incorporation Registered Agent: Carl C. Lang	Legal Action: Uncorrected Class II Notice of Noncompliance
Description: The facility was uncorrected based on their failure to ensure the following: One resident did not receive Remeron (an antidepressant) as ordered by his/her physician. The resident also did not receive his/her Lasix (a diuretic) as ordered by the physician in response to the resident's increased edema. One resident did not receive Lisinopril (used to treat hypertension) and Aldactone (diuretic used to treat hypertension and congestive heart failure) from 2/1/06-2/8/06, as ordered by his/her physician. One resident, with a history of weight loss, did not receive his/her nutritional supplement as ordered by the resident's physician. Facility staff failed to maintain the medication cart in a safe manner. One resident did not receive treatment as ordered by his/her physician for ulcers on his/her foot and facility staff failed to obtain laboratory tests as ordered for the resident.
Facility: Northgate Park Nursing Home Florissant, MO 158 Bed Skilled Nursing Facility Date of Notice: March 2006		Owner: Not Listed Operator: Prime Care Six, LLC Registered Agent: LexisNexis Document Solutions Inc.	Legal Action: Class I Notice of Noncompliance
Description: The facility failed to conduct and document a thorough assessment of a resident, failed to communicate adequate information to the resident's physician after repeated episodes of emesis and failed to administer an adequate supplemental oxygen supply when the resident was in respiratory distress. The resident died on the way to the emergency room.
Facility: Union Manor St. Louis, MO 52 Bed Residential Care Facility Date of Notice: March 2006		Owner: Cook, Alma Operator: LaTerryl Saddler Registered Agent: Alma Cook	Legal Action: Class I Notice of Noncompliance
Description: The facility failed to protect residents from verbal and physical abuse by two employees. Eight of ten residents interviewed witnessed or were victims of verbal or physical abuse by the operator of the facility and an aide employed at the facility.
Facility: Charlevoix Healthcare Center St. Charles, MO 142-Bed Skilled Nursing Facility Date of Notice: April 2006		Owner: Senior Trust of Charlevoix Operator: Seniortrust of Charlevoix, LLC Registered Agent: National Registered Agents, Inc.	Legal Action: Class I Notice of Noncompliance
Description: The facility failed to intervene and implement interventions to protect one resident who was repeatedly subjected to sexually inappropriate behavior from a family member. The resident had a history of chronic mental illness with accompanying impaired judgment and decision-making abilities. Facility staff were knowledgeable of the sexually inappropriate behavior and failed to report the incidents and failed to conduct an investigation.
Facility: Union Manor St. Louis, MO 52-Bed Residential Care Facility Date of Notice: April 2006		Owner: Alma Cook Operator: Alma Cook Registered Agent: None	Legal Action: Class I Notice of Noncompliance
Description: The facility failed to protect the health, safety and welfare of one resident who required oversight and supervision with medication and care. The facility informed the resident of an emergency discharge without adequate reason and without ensuring the safety of the patient.
Facility: Cori Manor Fenton, MO 22-Bed Residential Care Facility Date of Notice: April 2006		Owner: Cori Manor Assoc. Tenn. Gen Prtn Operator: Affiliated Healthcare, Inc. Registered Agent: Robert I. Falk	Legal Action: Uncorrected Class II Notice of Noncompliance
Description: A licensure inspection was completed on 2/10/06. The facility was not in substantial compliance. A revisit was completed on 4/13/06. The facility staff failed to maintain unobstructed fire exits, maintain the facility roof in good repair, ensure all opening to the outside screened or protected to prevent the entrance of insects, ensure dietary staff wore effective hair restraints, prohibit live animals in the dining room during meal service, protect food from potential contamination and failed to thaw frozen foods in a refrigerator or under potable running water.
Facility: Cori Manor Fenton, MO 124-Bed Skilled Nursing Facility Date of Notice: April 2006		Owner: Cori Manor Assoc. Tenn. Gen Prtn Operator: Affiliated Healthcare, Inc. Registered Agent: Robert I. Falk	Legal Action: Uncorrected Class II Notice of Noncompliance
Description: A survey was completed on 2/10/06. The facility was not in substantial compliance with participation requirements. A revisit was completed on 4/13/06. The facility staff failed to maintain floors, walls, doors and equipment and furniture in good repair. Facility staff failed to provide a thorough assessment of the resident's condition following a fall, obtain physician orders for treatment and accurately record medication administration for four residents. Also, the facility staff failed to protect food from potential contamination.
Facility: The Central Residence St. Louis, MO 41-Bed Residential Care Facility Date of Notice: April 2006		Owner: Garcia's Central Residence, LLC Operator: Same Registered Agent: Robert T. West	Legal Action: Class I Notice of Noncompliance
Description: The facility failed to provide adequate care to meet one resident's needs. The facility failed to administer medications as ordered by the resident's physician and adequately monitor a resident who experienced a change in condition. While waiting for emergency personnel the facility failed to monitor the resident's condition and immediately initiate cardio-pulmonary resuscitation when necessary. The resident expired on 3/6/06.
Facility: Autumn Ridge Herculaneum, MO 69-Bed Residential Care Facility Date of Notice: April 2006		Owner: Not Listed Operator: Emeritus Corporation Registered Agent: CT Corporation System	Legal Action: Uncorrected Class II Notice of Noncompliance
Description: A licensure inspection was completed on 6/9/05. Revisits were completed on 9/7/05, 11/28/05, 2/9/06 and 4/13/06. The facility is not in substantial compliance with participation requirements. The facility staff failed to ensure one resident was mentally and physically capable of negotiating a path to safety. Also, the facility failed to place ten residents who used walkers for ambulation or wheelchairs on a floor which has direct access to grade with a handrail in a non-sprinkled building.
Facility: Union Manor St. Louis, MO 52-Bed Residential Care Facility Date of Notice: April 2006		Owner: Not Listed Operator: Alma Cook Registered Agent: None	Legal Action: Class I Notice of Noncompliance
Description: The facility (sic) to protect residents from verbal and physical abuse and failed to follow the plan of correction developed by the facility Administrator.
Facility: Bellefontaine Gardens Nursing & Rehab St. Louis, MO 96-Bed Skilled Nursing Facility Date of Notice: May 2006		Owner: St. Louis Care LLC Operator: Bellefontaine Gardens Nursing & Rehab, Inc. Registered Agent: James Lincoln	Legal Action: Uncorrected Class II Notice of Noncompliance
Description: A survey was completed on 3/15/06. The facility was not in substantial compliance with participation requirements. A revisit was completed on 5/5/06. The facility staff failed to obtain physician orders and failed to monitor catheters and a tracheostomy. The facility failed to provide medications and oxygen as ordered for five residents. In addition, the facility failed to assess, monitor, provide follow-up care and notify the physician or family for four residents.
Facility: Cori Manor Fenton, MO 124-Bed Skilled Nursing Facility Date of Notice: June 2006		Owner: Cori Manor Associates, Tennessee Gen. Prtn. Operator: Affiliated Healthcare, Inc. Registered Agent: Robert I. Falk	Legal Action: Uncorrected Class II Notice of Noncompliance
Description: A licensure inspection was completed on 2/10/06. The facility was not in substantial compliance with participation requirements. Revisits were completed on 4/13/06 and 6/09/06. The facility staff failed to keep ceiling tiles, floors, walls, doors and furniture clean and in good repair in residents' rooms, two dining rooms, shower rooms and one corridor. As a result of the continued non-compliance the facility has been issued a directed plan of correction to correct the violations.
Facility: St. Louis Avenue Nursing Center St. Louis, MO 90-Bed Skilled Nursing Facility Date of Notice: June 2006		Owner: EBG Health Care II, Inc. Operator: Same Registered Agent: Ewing B. Gourley	Legal Action: Uncorrected Class II Notice of Noncompliance
Description: An annual survey was completed on 4/10/06. The facility was not in substantial compliance with participation requirements. A revisit was completed on 5/26/06. The facility staff failed to: provide written notification of discharge from the facility for one resident; facility staff failed to respond to residents in a respectful manner and cover or drape residents during personal care; maintain a clean, comfortable and homelike environment; develop plans of care to address the residents needs based on their comprehensive assessments; provide proper incontinence care for four residents; provide assess, provide treatment and pressure reduction devices to six residents at risk for pressure sore development; provide adequate supervision and monitoring to one resident who climbed over the roof and left the facility without staff knowledge; ensure a medication error rate of less than 5%; ensure staff washed their hands after providing care to five residents.
Facility: Christian Care Home Ferguson, MO 180-Bed Skilled Nursing Facility Date of Notice: August 2006		Owner: Christian Women's Benevolent Assoc. Operator: Same Registered Agent: Not Listed	Legal Action: Uncorrected Class II Notice of Noncompliance
Description: A survey was completed on 5/19/06. The facility was not in compliance with participation requirements. A revisit was completed on 7/27/06. The facility staff failed to monitor, report changes in condition and correctly administer medication for two residents. Staff failed to correctly administer Duragesic patches to one resident resulting in the resident having three patches on at one time. The resident was transferred to the hospital on 7/8/06 with respiratory distress. The hospital staff discovered the three patches and removed them and administered Narcan (a medication to reverse the effects of opiates, including breathing depression and sedation). In addition staff failed to administer two medications to another resident who experienced chest pain and shortness of breath.
Facility: The Riverview St. Louis, MO 120-Bed Skilled Nursing Facility Date of Notice: September 2006		Owner: Not Listed Operator: KJD Incorporated Registered Agent: Carl C. Lang	Legal Action: Class I Notice of Noncompliance
Description: The facility failed to monitor and ensure the safety of one resident (Resident #1) who exhibited delusional behaviors and expressed suicidal ideations. The resident was sent for evaluation on 8/12/06, and returned to the facility with a diagnosis of acute delirium with dementia and no changes were made to current medications. Facility staff failed to notify the physician and/or psychiatrist of the resident's return. The resident continued to exhibit delusional behaviors and stated he/she wanted to leave the facility. On 8/18/06, the resident went out the fourth floor window of his/her room and fell to his/her death.
Facility: Nursing & Rehab Center of U-City Loop University City, MO 130-Bed Skilled Nursing Facility Date of Notice: September 2006		Owner: Not Listed Operator: Nursing & Rehab Center of U-City Loop, LLC Registered Agent: Sharo Shirshekan	Legal Action: Class I Notice of Noncompliance
Description: The facility failed to notify the physician of a resident's attempts to elope. The facility failed to monitor and ensure the safety of one resident, who expressed the need to escape from the building and had a history of previous elopement attempts. The resident had attempted to leave the building on three occasions and staff implemented 15-minute checks. On 8/11/06 staff found the resident in the stairwell again. The resident told staff he/she knew he/she could not use the stairs or elevator, but would find a way to leave the building. Facility staff did not notify the resident's physician of the elopement attempts. On 8/13/06 at approximately 8:30 p.m., the resident attempted to escape from his/her third floor bedroom window and fell to his/her death. In addition the facility failed to notify a resident's legal representative of the resident's elopement from the facility, transfer to hospital and findings of a fracture.
Facility: Autumn View Gardens at Schuetz Road St. Louis, MO 100-Bed Assisted Living Facility Date of Notice: December 2006		Owner: Not Listed Operator: Bethesda Foundation Registered Agent: C T Corporation System	Legal Action: Class I & Uncorrected Class II Notice of Noncompliance
Description: A complaint investigation was completed on 9/06/06. The facility was not in substantial compliance with participation requirements. A revisit and complaint investigation was completed on 12/08/06. The facility failed to provide adequate oversight and supervision to one resident. The resident left the facility on two occasions, 12/02/06 and 12/03 through 12/04/06, unattended while the outside temperatures were below freezing, the sidewalks were covered in snow and it was dark outside.
Facility: Mason Manor St. Louis, MO 12-Bed Residential Care Facility Date of Notice: December 2006		Owner: Not Listed Operator: Cura, Inc. Registered Agent: Timothy G. Dolan	Legal Action: Class I Notice of Noncompliance
Description: Facility staff failed to ensure nine of nine residents could make an unassisted pathway to safety.
Facility: Parkview Residential Care Crystal City, MO 52-Bed Residential Care Facility Date of Notice: December 2006		Owner: Crystal City Operator: DMP Enterprises, Inc. Registered Agent: Mark C. Goldenberg	Legal Action: Class I & Uncorrected Class II Notice of Noncompliance
Description: A licensure inspection was completed on 9/19/06. The facility was not in substantial compliance with participation requirements. A complaint investigation and revisit was completed on 12/8/06. The facility failed maintain (sic) the temperature in the building above 68 degrees Fahrenheit. On 12/8/06 residents were observed wearing coats, hats and gloves during the breakfast meal. The temperature in the building measured between 56 and 60 degrees F. Also, the facility failed to maintain two unobstructed exits on the second floor.