Return to MCQC Nursing Home Non-Compliance Page

Missouri Long-term Care Facility Notices of Non-Compliance 2009

2009 Nursing Home Non-Compliance by Region: 1. Southwest Region 2. Southeast Region 3. Kansas City Region 4. Northwest Region 5. Northeast Region 6. Central Region 7. St. Louis Region

CENTRAL REGION
Facility: Riverdell Care Center Boonville, MO 60-Bed Skilled Nursing Facility Date of Notice: January 2009	Owner: Riverdell Real Estate LLC Operator: Boonville No. 2, Inc. Registered Agent: Clifton L. Shirrell	Legal Action: Class I Notice of Noncompliance In a letter from DHSS: On 1/16/2009, SLCR staff completed a revisit at the facility and determined that the Class I deficiency could be lowered to a Class II.
Description: Facility staff failed to provide adequate supervision and assistive devices to prevent accidents. Facility staff failed to provide monitoring and supervision for one resident (Resident #1) in accordance with the resident’s plan of care. Facility staff failed to ensure a bed alarm device remained in the on position to alert them of the resident’s attempts to get out of bed unassisted. Staff found the resident with his/her head between the bedrail and the mattress and his/her body resting on the floor. Staff assessed the resident had expired.
Facility: Eldercare RCF Sedalia, MO 12-Bed Residential Care Facility Date of Notice: January 2009	Owner: Reeves, Joyce A. Operator: Eldercare, LLC Registered Agent: Al Kroeger	Legal Action: Uncorrected Class II Notice of Noncompliance
Description:  At the fifth revisit of 01/15/2009, the facility was still noncompliant in the following areas: Fire Safety Standards: The facility failed to remove accumulated trash and combustible debris from the premises to prevent fire hazards and public health nuisance. Physical Plant Requirements: The facility failed to maintain residents’ furniture and facility equipments including chairs, mattresses and tables in good condition and repair. Dietary Requirements: The facility failed to ensure a qualified individual reviewed and documented the diet, food preparation and service for one resident who had a physician ordered modified diet. General Sanitation Requirements: The facility failed to ensure floors were maintained clean and in good repair. The kitchen flooring had accumulated black, brown, and tan stains, multiple cracks and missing linoleum tiles. The wood floor in one resident room showed dirt, debris, a cigarette on the floor and rodent feces along the dresser and behind a chair. Another resident’s room showed multiple dark stains and scuff marks and dried feline feces on the floor. The facility failed to use effective measures to minimize the presence of rodents. Bagged stuffing mix in the dry food pantry had several small holes and bread crumbs were on the shelf. A bag of candy on top of the dresser in one resident room had holes in the bag and there were rodent feces on top of the dresser; there were also rodent feces on the floor of the resident room. One resident said he/she had seen a mouse in the kitchen. Another resident said he/she caught a mouse in a mouse trap and had also seen a dead mouse in his/her bathroom. In addition, a new Class II violation was found in the area of Physical Plant Requirements. The facility failed to ensure floors were maintained clean and i good repair. Staff failed to provide routine maintenance to ensure the soffit, fascia board, and guttering around the exterior of the building were structurally maintained in good repair. Staff failed to ensure the ceiling in the Activity room and wall in at least one resident room (#5) were structurally maintained and in good repair.
Facility: Parkside Manor Columbia, MO 120-Bed Skilled Nursing Facility Date of Notice: February 2009	Owner: Columbia Ventures, LLC Operator: N & R of Columbia, LLC Registered Agent: Charlotte Stutts	Legal Action: Class I Notice of Noncompliance
Description: Facility staff failed to: Ensure exits are readily accessible at all times. Four of four designated exit doors which had delayed-egress locks did not comply with the Life Safety Code (LSC) requirements for special locking arrangements. One of one courtyard gates did not contain a handle to release the latch which prevented evacuation for 12 residents that live on the Special Care Unit in the event of an emergency. Note: At the time of the exit conference of 02/05/2009 staff ensured the Special Care Unit exit doors were unobstructed, the magnets on the door that leads from the unit into the facility was dismantled, and the courtyard gates were opened, abating the immediate jeopardy. The facility had not completed inservice education of all staff regarding emergency evacuation procedures and the grid placement was lowered to a Class II violation. Provide a properly installed, tested and maintained fire alarm system. NOTE: At the time of the exit conference of 02/05/2009 staff ensured a Fire Alarm Technician replaced the batteries, tested the system in emergency battery backup mode, and completed the state Fire Alarm Inspection form certifying the system was properly functioning and abating the immediate jeopardy. Staff had not completed inservice education of Maintenance staff to ensure routine assessment and maintenance of the Fire Alarm system were ongoing and the grid placement was lowered to an F.
Facility: Ashley Manor Care Center Boonville, MO 52-Bed Skilled Nursing Facility Date of Notice: April 2009	Owner: Ashley Manor, Inc. Operator: Same Registered Agent: Hal Juckette	Legal Action: Uncorrected Class II Notice of Noncompliance
Description: At the revisit, the facility failed to provide a properly tested and maintained fire alarm system. The facility census was 38.
Facility: Lake Ozark Retirement Center Osage Beach, MO 40-Bed Residential Care Facility Date of Notice: April 2009	Owner: Lierman Family Co. Operator: Carl Lang Registered Agent: Not Listed	Legal Action: Class II Notice of Noncompliance
Description: The facility failed to maintain the smoke detectors interconnected to the complete fire alarm system.
Facility: Seville Care Center Salem, MO 90-Bed Residential Care Facility Date of Notice: May 2009	Owner: BJB Industries, Inc. Operator: Community Care Center of Salem, Inc. Registered Agent: James Giardina	Legal Action: Class I Notice of Noncompliance In a letter from DHSS: On 05/11/2009, SLCR staff completed a revisit at the facility and determined that the Class I deficiency could be lowered to a Class II.
Description: The facility staff failed to transport one dependent resident in a safe manner in accordance with his/her needs. Staff failed to apply wheelchair footrests to the resident’s wheelchair prior to transporting him/her to the local hospital about 1/8 of a mile from the facility. Staff did not put shoes on the dependent resident’s feet, and failed to ensure the resident’s feet did not make contact with the asphalt during the transport, resulting in the loss of skin and underlying tissue on seven of the resident’s toes and exposing the bone on at least two toes.
Facility: Eldercare RCF Sedalia, MO 12-Bed Residential Care Facility Date of Notice: May 2009	Owner: Reeves, Joyce A. Operator: Eldercare, LLC Registered Agent: Alexander Kroeger	Legal Action: Uncorrected Class II Notice of Noncompliance
Description: At the sixth revisit, the facility failed to correct the following violations. The facility census was 11. General Sanitation requirements: Throughout the facility, staff failed to use effective measures to minimize the presence of rodents and insects and failed to ensure floors were maintained clean and in good repair. Physical Plant requirements: The facility failed to maintain residents’ furniture and facility equipment including chairs and mattresses clean and in good condition and repair; failed to ensure floors were maintained clean and in good repair and failed to provide routine maintenance to ensure the fascia board and guttering around the exterior of the building were structurally maintained in good repair.
Facility: Lee House, LLC Eldon, MO 53-Bed Residential Care Facility Date of Notice: June 2009	Owner: Blue Spring Creek Properties, LLC Operator: Lee House, LLC Registered Agent: Gale Carlson	Legal Action: Class I Notice of Noncompliance
Description: The facility staff failed to implement measures to ensure one confused resident with a history of wandering was safe. The resident exhibited increased confusion and wandering and left the facility without staff knowledge. At 5:15 a.m., a community member found the resident walking in the road toward oncoming traffic and returned the resident to the facility. The facility census was 27.
Facility: Victorian Estates Belle, MO 30-Bed Residential Care Facility Date of Notice: July 2009	Owner: Vaughan, Lisa & Clint Operator: Victorian Residential Care, LLC Registered Agent: Lisa Watson	Legal Action: Uncorrected Class II Notice of Noncompliance
Description: At the revisit, the facility failed to correct the following Fire Safety Standards: The facility failed to install a range hood extinguishing system in the kitchen. The facility failed to ensure the fire alarm system would automatically transmit to the fire department, dispatching agency or central monitoring company upon activation of the system.
Facility: Eldercare RCF Sedalia, MO 12-Bed Residential Care Facility Date of Notice: July 2009	Owner: Reeves, Joyce A. Operator: Alexander Kroeger Registered Agent: N/A	Legal Action: Uncorrected Class II Notice of Noncompliance
Description: A licensure inspection was completed on 03/16/2009. The facility was not in substantial compliance with participation requirements. A revisit was completed on 07/08/2009. The facility failed to take corrective action in the following areas: Install fire alarm components in accordance with State Statute and National Fire Protection Association (NFPA) 72. The facility failed to ensure the fire alarm pull boxes were installed and accessible by staff. Install heat and smoke detectors interconnected to the complete fire alarm system in all accessible spaces. To properly install the gas fired water heater.
Facility: Melody House Jefferson City, MO 15-Bed Residential Care Facility Date of Notice: July 2009	Owner: W. B. Price, Inc. Operator: New Horizons Community Support Registered Agent: Not Listed	Legal Action: Uncorrected Class II Notice of Noncompliance
Description: The facility failed to provide smoke stop partitions.
Facility: Ridgeway Residential Care Sullivan, MO 20-Bed Residential Care Facility Date of Notice: August 2009	Owner: Turner, Deborah J. Operator: Deborah Turner Registered Agent: Not Listed	Legal Action: Uncorrected Class II Notice of Noncompliance
Description: The facility failed to provide required fire extinguishers. The facility failed to provide a complete fire alarm system. The facility failed to have fire rated or treated drapes. The facility failed to provide two smoke sections in the building.
Facility: Ridgeway Residential Care Sullivan, MO 20-Bed Residential Care Facility Date of Notice: August 2009	Owner: Turner, Deborah J. Operator: Deborah Turner Registered Agent: Not Listed	Legal Action: Uncorrected Class II Notice of Noncompliance
Description: The facility failed to complete community based assessments as required for three residents. In addition, the facility failed to ensure the staff member responsible for completing the assessments was appropriately trained. The facility census was 18.
Facility: Eldercare RCF I Sedalia, MO 12-Bed Residential Care Facility Date of Notice: August 2009	Owner: Reeves, Joyce A. Operator: Alexander Kroeger Registered Agent: Not Listed	Legal Action: Uncorrected Class II Notice of Noncompliance
Description: The facility failed to have a complete fire alarm system in accordance with NFPA 101 Section 18.3.4, 2000 edition.
Facility: Villa Marie Skilled Nursing Facility Jefferson City, MO 120-Bed Skilled Nursing Facility Date of Notice: September 2009	Owner: Lierman Family Co. Operator: Eldercare of Mid-Missouri VII, Inc. Registered Agent: Carl Lang	Legal Action: Class I Notice of Noncompliance
Description: The facility failed to properly assess one resident with an unsteady gait and failed to implement interventions to prevent falls. The resident fell at the facility and sustained a head injury which resulted in the resident’s death.
Facility: Harambee House, Inc. Columbia, MO 15-Bed Residential Care Facility Date of Notice: September 2009	Owner: Harambee House, Inc. Operator: Same Registered Agent: Not Listed	Legal Action: Uncorrected Class II Notice of Noncompliance
Description: The facility failed to properly install a complete fire alarm system in accordance with NFPA 72 1999 edition. The facility failed to properly maintain electromagnetic hold open devices providing separation between floors.
Facility: Stoney Ridge Village Sedalia, MO 160-Bed Residential Care Facility Date of Notice: September 2009	Owner: Sedalia Health Group LLC Operator: AHG-Stoney Ridge, LLC Registered Agent: Not Listed	Legal Action: Uncorrected Class II Notice of Noncompliance
Description: The facility failed to install and maintain the range hood extinguishing system. The facility failed to have inspections and written certifications of the complete fire alarm system. The facility failed to properly install and maintain a complete fire alarm system. The facility failed to install smoke detectors interconnected to the fire alarm system. The facility failed to install smoke stop partitions on each floor. The facility failed to maintain smoke barrier separation between floors. The facility failed to install self closing devices on doors providing separation between floors. The facility failed to treat or certify the treatment of curtains and drapes in the facility as flame resistant. The facility failed to maintain the electrical system in good repair.
Facility: Heritage Park Skilled Care Rolla, MO 120-Bed Skilled Nursing Facility Date of Notice: October 2009	Owner: CRAVIV, LLC Operator: Cathedral Rock of Rolla, Inc. Registered Agent: Anthony Soukenik	Legal Action: Class I Notice of Noncompliance
Description: The facility failed to provide two residents personal attention and nursing care in accordance with his/her condition and consistent with current acceptable nursing practice. Facility staff failed to administer intravenous (IV) fluids and IV antibiotics as ordered for two residents with dehydration and infections. Facility staff further failed to obtain a laboratory blood sample as directed for one of the residents and did not notify the resident’s physician of the failure. Staff failed to administer any medications by mouth (including anti-seizure medication) to one of the residents (who was hospitalized on 09/11 for a seizure) on 09/12 and 09/13 and did not notify the resident’s physician of the failure to administer the medications. The facility census was 101.
Facility: Jefferson City Nursing & Rehabilitation Center, LLC Jefferson City, MO 120-Bed Skilled Nursing Facility Date of Notice: November 2009	Owner: HCRI Missouri Properties LLC Operator: Jefferson City Nursing & Rehab Center, LLC Registered Agent: CSC - Lawyers Incorporating Service Company	Legal Action: Uncorrected Class II Notice of Noncompliance
Description: The facility staff failed to follow the facility bowel movement (BM) protocol for three dependent residents and the facility staff failed to transfer orders for five of 16 sampled residents.
Facility: Stoney Ridge Village Sedalia, MO 160-Bed Residential Care Facility Date of Notice: December 2009	Owner: Sedalia Health Group, LLC Operator: AGH-Stoney Ridge, LLC Registered Agent: Not Listed	Legal Action: Uncorrected Class II Notice of Noncompliance
Description: The facility failed to install and maintain electrical wiring in accordance with the requirements of the National Electrical Code, 1999 edition.
Facility: Victorian Estates II Belle, MO 30-Bed Residential Care Facility Date of Notice: December 2009	Owner: Watson, Lisa & Vaughan, Clint Operator: Victorian Residential Care, LLC Registered Agent: Lisa Watson	Legal Action: Class I and Uncorrected Class II Notice of Noncompliance
Description: The facility failed to correct a problem with the alarm system for at least 12 days after the monitoring company notified facility staff that the monitoring company was not receiving the fire alarm signal. In addition, the facility had the following uncorrected Class II violations. The facility failed: To ensure resident use bathrooms were maintained clean and in good repair. To maintain furniture and equipment clean and in good repair including chairs, pillows and mattresses. To provide routine housekeeping services necessary to maintain resident rooms in a safe, clean and sanitary manner. The Owner/Manager failed to devote sufficient time to the management of the facility to assure compliance with all applicable laws and regulations based on the Class I and uncorrected Class II violations.

KANSAS CITY REGION
Facility: Foxwood Springs Living Center Raymore, MO 108-Bed Skilled Nursing Facility Date of Notice: January 2009	Owner: BLC-Foxwood Springs, LLC Operator: Same Registered Agent: C T Corporation System	Legal Action: Uncorrected Class II Notice of Noncompliance
Description: The facility staff failed to ensure physician’s ordered laboratory blood tests for PT/INR were drawn for one resident with physician’s orders to receive Coumadin of 13 sampled residents.
Facility: Garden Valley Nursing & Rehabilitation Center Kansas City, MO 150-Bed Skilled Nursing Facility Date of Notice: January 2009	Owner: Garden Valley Real Property, LLC Operator: Garden Valley Nursing & Rehabilitation Center, LLC Registered Agent: Kimberly Kusack	Legal Action: Uncorrected Class II Notice of Noncompliance
Description: The facility failed to assure staff followed the standard of practice to monitor the amount of gastric residual (amount of food remaining in the stomach) for one resident (Resident #34) with gastrostomy tube (tube surgically inserted through the abdominal wall into the stomach to provide liquid food, fluids and medications) feedings. The resident had a history of vomiting. The facility also failed to act upon the registered dietician’s recommendation to decrease the amount of tube feeding and increase the frequency of tube feedings for a second resident (Resident #24) with a tube feeding who displayed symptoms of not tolerating the feedings. The facility failed to provide safe emergency access from the exit discharge areas according to NFPA 101, 19.2.1. when exit passageways (sidewalks) were snow covered or had hard packed snow mounds preventing access to the public way (parking lot). This affected 8 of 11 exits.
Facility: Meyer Care Center Higginsville, MO 40-Bed Skilled Nursing Facility Date of Notice: January 2009	Owner: George J. & Hilda Meyer Foundation Operator: Same Registered Agent: Not Listed	Legal Action: Class I Notice of Noncompliance
Description: The facility staff failed to ensure one resident (Resident #1) of three sampled residents, with a terminal illness received professional, appropriate and humane end-of-life care in accordance with the natural progression of the dying process. Facility nursing staff hastened the resident’s dying process when facility staff on 12/29/08 at approximately 10:00 p.m. removed the resident’s oxygen, lowered the head of the resident’s bed, elevated the resident’s feet, which caused the resident’s body fluids to accumulate in the resident’s lungs. The body position of the resident decreased oxygen flow to the resident’s lungs and removal of the resident’s oxygen deprived the resident of oxygen to breathe. The facility failed to ensure Resident #1 was protected from inappropriate care when facility staff present during this incident did not intervene on behalf of the resident. On 12/29/08 at 10:20 p.m., the resident expired according to the facility nurses’ notes. The facility failed to ensure facility staff had adequate end-of-life education and knowledge of procedures to follow for a resident in the dying process. The facility staff failed to notify or consult with Resident #1’s physician or hospice provider for additional comfort measures appropriate for the resident’s end-of-life care.
Facility: Jefferson Health Care Lee’s Summit, MO 120-Bed Skilled Nursing Facility Date of Notice: January 2009	Owner: DCB Real Estate Partnership Operator: Jefferson Health Care, Inc. Registered Agent: Clifton L. Shirrell	Legal Action: Class I Notice of Noncompliance
Description: Based on observation, interview and record review, the facility failed to monitor one resident, assessed with short- and long-term memory problems, poor decision making skills, wandering, door seeking behavior and at risk for elopement, to assure the resident did not leave the facility without staff protective oversight. Resident #1 left the facility on 12/22/08 without staff’s knowledge, and the resident was last seen by staff after the resident’s 4:30 a.m. medication administration. On 12/22/08, weather conditions were 1.0 to 1.9 degree Fahrenheit (^oF) sky clear and the wind at 4.6 miles per hour (mph). Dietary staff (DS) A drove into the facility’s West parking lot at approximately 5:15 a.m. and saw the resident sitting in the facility’s parking lot half-way between the West exit door and the back of the building. The resident was sitting in a merry walker (specialty chair on wheels with a PVC pipe material frame around the seat). DS A alerted staff on duty. On 12/22/08, staff failed to notify Resident #1’s physician and family regarding the resident’s elopement from the facility; nursing staff failed to assess the resident; staff failed to complete an elopement risk assessment and implement interventions for the resident’s safety. Resident #1 left the facility without staff’s knowledge on 12/27/08. The weather conditions during this time period gradually dropped from 57.2 to 39.2^o F the wind between 63.3 mph and 25.3 mph with overcast skies and rain. A person delivering newspapers saw Resident #1 sitting in a merry walker down a hill in a grassy area between the facility’s West parking lot and the housing development to the West of the facility. Facility staff were not aware the resident was missing until staff were alerted by the person delivering newspapers. The facility also failed to ensure the outside South courtyard door in the Special Care Unit (SCU) was securely latched and locked on 01/13/09. The weather conditions during this time period on 1/13/09 were 24.1^oF with scattered clouds and the wind at 10.4 mph. The facility census was 63 residents.
Facility: The Greens at Creekside Kansas City, MO 180-Bed Skilled Nursing Facility Date of Notice: January 2009	Owner: Choudhary International, LLC Operator: Fayjay, Inc. Registered Agent: Stephanie Hazelton	Legal Action: Uncorrected Class II Notice of Noncompliance
Description: The facility failed to implement safe transfer techniques for one of three sampled residents (Resident #134) when one staff member transferred the totally dependent resident using a mechanical lift. The facility identified three residents on Resident #134’s hall that required transfer with the mechanical lift. The facility failed to follow their infection control policy and implement procedures to prevent the spread of a possible communicable skin disease. This affected one resident (Resident #131) of four residents the facility identified with rashes and had the potential to affect other residents.
Facility: Rosewood Health Center Independence, MO 300-Bed Skilled Nursing Facility Date of Notice: March 2009	Owner: Not Listed Operator: The Groves Registered Agent: Karen Minton	Legal Action: Class I Notice of Noncompliance
Description: The facility staff failed to assess the safety and use of a side rail locked in the transfer/assist position on a high/low bed in the lowest position for one resident (Resident #1) on the Special Care Unit of five sampled residents, who could exit the bed which resulted in the death of the resident. The facility staff failed to consider the resident’s ability to exit his/her bed and the risks of entrapment when using a side rail on a high/low bed in the lowest position, which prevented a safe exit and/or entrance from/into the bed. This resulted in the resident becoming entrapped between the side rail and his/her bed mattress with his/her face and nose pressed against the bed mattress which resulted in the resident’s death on 3/3/09, due to Entrapment Asphyxia (a condition caused by an insufficient intake of oxygen). The facility staff also failed to assess the length of the string attachment to the resident’s personal body alarm attached to his/her gown and the side rail. As a result of the resident having a long string attachment, his/her personal body alarm did not activate or sound for staff to be alerted to the resident’s movement out of the bed. Further, the facility staff failed to communicate to all nursing staff and to the care plan team regarding the resident’s known behavior of being able to independently roll onto his/her right side, restless movements of his/her legs/body within and off of his/her bed and/or his/her ability to slide down in bed, in relationship to the resident’s use of his/her side rail left in the locked transfer/assist position when the resident was left alone in bed unsupervised. The facility staff has identified five additional at risk residents.
Facility: Monterey Park Nursing Center Independence, MO 122-Bed Skilled Nursing Facility Date of Notice: March 2009	Owner: Acorn Health Centers, Inc. Operator: Monterey Park Nursing Center, Inc. Registered Agent: Joseph Tutera	Legal Action: Class I Notice of Noncompliance
Description: The facility failed to provide supervision and care to prevent an avoidable fall for one resident the facility identified as confused and a fall risk. When the resident was in bed, facility staff raised the bed rails. Facility staff had identified the resident would remove his/her personal alarm and made repeated attempts to climb out of bed. Staff failed to develop and implement care plan interventions to address those behaviors. On 2/20/09 during the night shift, staff had identified the resident was restless and had tried to climb out of bed. Later in the shift, the resident’s roommate alerted staff that the resident had fallen out of bed. When staff arrived in the resident’s room, the resident’s personal alarm was lying on the bed and not sounding. The resident was lying on the floor next to the bed. When transferred to the hospital, x-rays showed the resident had spiral fractures to both femurs (thigh bone) that required surgical repair. The facility census was 113 residents.
Facility: Life Care Center of Grandview Grandview, MO 172-Bed Skilled Nursing Facility Date of Notice: March 2009	Owner: Grandview Medical Investors, LLC Operator: United Investors Limited Registered Agent: C T Corporation System	Legal Action: Uncorrected Class II Notice of Noncompliance
Description: The facility failed to maintain correct physician’s orders on the Medication Administration Record (MAR) for one of 14 sampled residents (Resident #28). The facility failed to ensure four of six areas without negative airflow during the original survey had negative airflow at the revisit potentially affecting at least 35 residents residing in or using those areas. The exhaust/ceiling vents failed to operate in the therapy area shower room, the 600 Hall soiled utility room, the 500 Hall soiled utility room, and the 500 Hall shower room. The facility failed to return to the pharmacy unit dose medications within 30 days after a resident was discharged, for two supplemental residents (Supplemental Resident #130 and #132).
Facility: Leona House Kansas City, MO 7-Bed Assisted Living Facility Date of Notice: April 2009	Owner: W.H.E. Homes, LLC Operator: Same Registered Agent: Capitol Corporate Services, Inc.	Legal Action: Uncorrected Class II Notice of Noncompliance
Description: At the revisit on 03/30/2009, the facility failed to: Ensure residents were free of physical restraints. The staff restrained one resident with a reclining chair and tray. Ensure staff provided privacy for one resident when staff had the resident sleep on the sofa at night instead of in his/her bed.
Facility: Cedar Valley Health Center Raytown, MO 154-Bed Skilled Nursing Facility Date of Notice: April 2009	Owner: Missouri Regency Associates, LLC Operator: Deaconess Long Term Care of Missouri, LLC Registered Agent: The Corporation Company	Legal Action: Class I Notice of Noncompliance In a letter from DHSS: On 4/09/2009, SLCR staff completed a revisit at the facility and determined that the Class I deficiency could be lowered to a Class II.
Description: The facility failed to prevent one resident from acquiring an avoidable unstageable pressure ulcer; failed to accurately and consistently assess and document the condition of the pressure ulcer; failed to notify the resident’s physician of changes and deterioration of the pressure ulcer; failed to provide standard interventions such as turning and repositioning, off loading the pressure ulcer, and evaluating the resident’s tissue tolerance; failed to implement the physician’s order for providing daily treatments and dressing changes; failed to develop and update a comprehensive care plan for the pressure ulcer; failed to coordinate and communicate the pressure ulcer’s status, treatment, and interventions to promote healing of the pressure ulcer with the Hospice provider, and failed to notify the Registered Dietician about the change of status/deterioration of the pressure ulcer to obtain nutritional interventions to promote healing of the pressure ulcer. The facility census was 86.
Facility: Woodbine Healthcare & Rehab Center Gladstone, MO 300-Bed Skilled Nursing Facility Date of Notice: April 2009	Owner: Diamond Senior Living Operator: Woodbine HealthCare, LLC Registered Agent: CSC-Lawyers Incorporating Service Company	Legal Action: Class I Notice of Noncompliance In a letter from DHSS: On 4/03/2009, SLCR staff completed a revisit at the facility and determined that the Class I deficiency could be lowered to a Class II.
Description: The facility failed to provide care and services to meet the needs of the residents and failed to be free of significant medication errors. The facility failed to: Assure staff adequately monitored one resident who they identified with a decline in condition. Staff left the resident, who was a Full Code, unattended while waiting for emergency transport to the hospital. The resident was found pulseless and not breathing by the Emergency Medical Services personnel. The resident suffered cardiopulmonary arrest and died. The facility census was 203. Staff failed to administer physician ordered insulin before supper to one resident that resulted in a critically high blood sugar level (over 500) and a change in the resident’s behavior. When staff would not administer the resident any insulin, the resident opened the medication cart, obtained a syringe and bottle of insulin and gave himself/herself an insulin injection. The facility transferred the resident to the hospital for a psychiatric evaluation due to the resident’s behavior. Ambulance personnel found the resident’s blood sugar level was 464 more than an hour after the resident administered himself/herself insulin. The hospital admitted the resident for evaluation of his/her behavior and treatment for hyperglycemia (high blood sugar).
Facility: The Villages of Jackson Creek Independence, MO 120-Bed Skilled Nursing Facility Date of Notice: April 2009	Owner: Not Listed Operator: Independence Operations, LLC Registered Agent: Capitol Corporate Services	Legal Action: Class I Notice of Noncompliance In a letter from DHSS: On 4/10/2009, SLCR staff completed a revisit at the facility and determined that the Class I deficiency could be lowered to a Class II.
Description: The facility failed to document, failed to report to the physician, and failed to follow facility protocol regarding three open areas on buttocks for one resident after notification by the Certified Nursing Assistant (CNA) to the charge nurse and the Director of Nursing (DON) on the resident bath sheets dated 2/18/09, 2/25/09, and 2/27/09 resulting in the development of two Stage II (a partial thickness loss of skin layers that presents as an abrasion, blister, or swallow (sic) crater) and one unstageable (full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green, or brown) and/or eschar (tan, brown, or black) in the wound bed) avoidable, facility-acquired pressure ulcers that were identified by Department of Health and Senior Services (DHSS) surveyors on 3/17/09. Following identification, the facility failed to notify the resident’s physician, failed to obtain authorization from the physician for a telephone order to administer a treatment, and failed to notify the resident’s physician when unauthorized medication was unavailable for 48 hours. The facility staff administered the unauthorized treatment to the pressure ulcers and failed to document and communicate wound characteristics and measurements since 3/17/09. The facility census was 96 residents.
Facility: Blue Ridge Nursing Home Kansas City, MO 38-Bed Intermediate Care Facility Date of Notice: April 2009	Owner: Carroll, Frank Jr. & Lisa M. Operator: Carroll Care Centers, Inc. Registered Agent: Jeffrey Lucas	Legal Action: Uncorrected Class II Notice of Noncompliance
Description: The facility failed to reconcile residents’ medications with the Medication Administration Record (MAR), did not instruct the proper usage of an inhaler for one resident (Resident #1), and did not instruct the proper usage of an inhaler for one resident (Resident #1), and did not sign the MAR when medications were given, affecting five (Residents #1, #2, #3, #4, and #5) of 37 residents.
Facility: Myers Nursing & Convalescent Center Kansas City, MO 84-Bed Skilled Nursing Facility Date of Notice: May 2009	Owner: G L Enterprises, Inc. Operator: Myers Nursing Home, Inc. Registered Agent: Gary Marvine	Legal Action: Uncorrected Class II Notice of Noncompliance
Description: The facility staff failed to ensure the restroom ceiling vents were free of dust and debris in the resident rooms of five residents (Resident #3, #7, #8, #10, #16,) of nine sampled residents, failed to maintain the floor of resident room 29-32 free of grime and a buildup of dirt and hair, and failed to maintain two ceiling vents free of a heavy buildup of dust in the dining room located over tables where people eat potentially affecting 81 of 83 residents who eat their food in the dining room. The facility staff failed to complete the Medication Administration Record (MAR) to indicate one supplemental resident (Supplemental Resident #102) received a daily medication as ordered by his/her physician out of nine sampled residents. The facility staff failed to serve the correct diet and failed to update the resident’s care plan to reflect the resident’s preferences, likes and dislikes and the change in the resident’s diet orders for one sampled resident (Resident #3) of nine sampled residents. The facility staff failed to obtain a complete physician’s order for the use of a Continuous Positive Airway Pressure machine (CPAP, a machine used to deliver a stream of compressed air via a hose to a nasal pillow, nose mask or full-face mask, opening the airway so that unobstructed breathing becomes possible when a person is sleeping) and failed to obtain a complete physician’s order for oxygen use that would contain the amount of liter flow of oxygen, if the oxygen is supposed to be continuous or when needed (prn) and how it should be delivered by a nasal cannula or a mask for one sampled resident (Resident #11), and failed to obtain a specific physician’s order for oxygen use for one sampled resident (Resident #8) out of nine sampled residents. The facility staff failed to follow their oxygen therapy and tubing care policy for sanitary maintenance of respiratory equipment by failing to date when the oxygen tubing and nasal cannula were changed and placed in a clean protective covering when not in use, and failed to have documentation of oxygen tubing changes on the Medication Administration Record (MAR) or Treatment Administration Record (TAR) or the Physician’s Order Sheets (POS) for one sampled resident (Resident #8), out of nine sampled residents. The facility failed to ensure the south smoke barrier wall located close to the south nurse’s station was sealed or extended from outside wall to outside wall or from the floor to the ceiling deck. This practice potentially affected at least 23 residents in one smoke zone of the facility. The facility failed to ensure the North Hall soiled utility room door was self-closing. This practice potentially affected one smoke zone where there are at least 15 residents who reside in the smoke zone. The facility failed to ensure one exit door opened when it was pushed during the fire alarm test, potentially affecting at least 15 residents who use the activities area smoke zone.
Facility: Bridgewood Health Care Center Kansas City, MO 162-Bed Skilled Nursing Facility Date of Notice: June 2009	Owner: Bridgewood Associates, LLC Operator: Bridgewood Health Care Center, LLC Registered Agent: Robert Craddick	Legal Action: Class I Notice of Noncompliance
Description: The facility staff failed to provide services based on the assessment and psychological history of the resident to attain the resident’s highest psychosocial well-being; failed to provide sufficient monitoring of the resident to prevent the resident from self harm when the resident’s behaviors escalated; failed to provide documentation of non-pharmacological interventions used to address aggressive and agitated behaviors before medicating the resident; and failed to re-evaluate and provide psychological treatment in a timely manner to one resident who had a history of suicidal ideation and attempts in January and April 2009 (Resident #11); failed to provide specialized mental health treatment services for four of 21 sampled residents (Residents #20, #24, #11 and #101) whose Preadmission Screening and Resident Review (PASRR, a required form used by the Missouri Department of Health and Senior Services to meet the federal mandate, 42CFR483.SubpartC, and reviewed by the Missouri Department of Mental Health if screening requirements are met to determine the level of services appropriate for residents with serious mental illness or mental retardation) indicated these services were necessary because of mental illness; failed to update one sampled resident’s care plan (Resident #20) following suicidal ideation; failed to provide psychotherapy consultations for residents who have Medicaid as their payor source which potentially affected 132 residents; and failed to maintain the PASRR assessments in the facility for one of 21 sampled residents (Resident #20) preventing staff from being able to incorporate the PASRR assessments into the resident’s comprehensive treatment and care plans.
Facility: Holmesdale Healthcare and Rehabilitation Center Kansas City, MO 100 Bed Capacity Skilled Nursing Facility Date of Notice: July 2009	Owner: Holmesdale Property LLC Operator: Holmesdale Healthcare and Rehabilitation Center, LLC Registered Agent: National Registered Agents, Inc.	Legal Action: Uncorrected Class II Notice of Noncompliance
Description: The facility staff failed to perform pressure ulcer care and incontinence care in a manner to prevent contamination of one resident’s facility-acquired pressure ulcers; failed to follow a physician’s order to ensure that one resident had a heel lift in use while in bed; failed to follow a physician’s order to cover one resident’s right heel pressure ulcer with a dressing; and failed to develop and provide pressure relief interventions such as pressure relief boots or padding a wheelchair foot rest after a heel ulcer was identified for one resident (Resident #22) out of nine sampled residents. The facility staff failed to ensure one resident (Resident #22) was transferred in a safe manner using a stand-up lift (an electric lift device that enables staff to transfer a resident while the resident supports their own weight), out of nine sampled residents. The facility staff failed to ensure medications are given free of errors for four randomly sampled residents (Residents #201, #202, #203, and #204) involving the appropriate type of medication administered; ensure the appropriate dosage of medication was administered; ensure the appropriate resident’s medication was administered; and ensure an inhaler was administered using the appropriate technique. Forty-two medication opportunities were observed. The acceptable medication error rate is less than 5%. The facility’s medication error rate was 9.5%. The facility staff failed to maintain all resident-use corridors free of obstructions so they could be used in case of emergency. This deficient practice affects 62 residents (11 residents on the 100 corridor, 25 residents on the 200 corridor, and 26 residents on the 400 corridor), staff and visitors in three of seven main floor smoke zones in the event of an emergency requiring an internal or external evacuation.
Facility: The Villages of Jackson Creek Independence, MO 120-Bed Skilled Nursing Facility Date of Notice: July 2009	Owner: KCHR Senior Care LLC Operator: Independence Operations, LLC Registered Agent: Capitol Corporate Services, Inc.	Legal Action: Uncorrected Class II Notice of Noncompliance
Description: The facility staff failed to address five sampled residents’ (Residents #40, #44, #38, #47, and #48) and two supplemental residents’ (Residents #106 and #302) care needs when staff failed to answer the residents’ call lights in a timely manner of 14 sampled residents. The facility staff failed to address two residents’ (Residents #32 and #35) need for pain medication and failed to address five residents’ (Residents #45, #29, #32, #41, and #46) toileting and incontinence care needs when the facility staff failed to answer the residents’ call lights in a timely manner of 14 sampled residents.
Facility: Oak Grove Nursing & Rehab. Oak Grove, MO 90-Bed Skilled Nursing Facility Date of Notice: August 2009	Owner: Grove Oak-Cal Assoc. LP Operator: N & R of Oak Grove, LLC Registered Agent: Charlotte Stutts	Legal Action: Class I Notice of Noncompliance
Description: Facility staff failed to obtain a physician’s order for the use of an indwelling urinary catheter including the diagnosis indicating its medical necessity; failed to obtain a physician’s order prior to the removal of the indwelling catheter; failed to monitor the resident’s urinary output after the removal of the urinary catheter and to communicate to the following shift that the resident’s indwelling urinary catheter had been removed so the staff could monitor the resident’s urinary output and monitor if the resident was retaining urine which occurred and resulted i “horrible” or “awful” pain to the resident.
Facility: Butterfly Haven Kansas City, MO 12-Bed Residential Care Facility Date of Notice: August 2009	Owner: Not Listed Operator: Cameron Scarlett Registered Agent: Not Listed	Legal Action: Uncorrected Class II Notice of Noncompliance
Description: The facility failed to have a fire watch plan in place in the event the facility’s fire alarm system is out of service for more than four hours in a 24 hour period, affecting 11 of 11 residents. The facility failed to discard expired foods and ensure food located in the cabinet and in the freezers was in sound condition, potentially affecting 11 of 11 residents. The facility failed to maintain a record of the residents’ personal possessions. The facility failed to maintain written authorization of resident expenditures. The facility failed to provide a written statement showing the current balance and all transactions to the resident, or his/her designee on a quarterly basis. The facility also failed to reconcile the current month’s resident trust fund account with the current month’s bank statement for the past 12 months. The facility failed to maintain resident funds documentation supporting the reconciliation of all records and receipts for the period of May, 2008 – April, 2009, as all records and receipts are required to be maintained for at least seven (7) years from the end of the fiscal year during which the records were originally made. This affected all residents. The facility failed to maintain in the facility and/or make available for review and copying within twenty-four hours of request by the Department of Health and Senior Services (DHSS) inspectors, all records related to resident funds. This affected all residents.
Facility: Golden Years Harrisonville, MO 132-Bed Skilled Nursing Facility Date of Notice: August 2009	Owner: Deaconess Long Term Care of Missouri, Inc. Operator: Same Registered Agent: The Corporation Company	Legal Action: Uncorrected Class II Notice of Noncompliance
Description: The facility staff failed to re-evaluate and fully assess for safety and appropriateness the use of a self-release seat belt type restraint for one of ten sampled residents (Resident #21) who had a history of seizures (the involuntary jerking of extremities and loss of consciousness caused by electrical discharges within the brain). The facility staff failed to follow professional standards of practice by not consistently and thoroughly documenting fluid intake and urinary output for one of ten sampled residents (Resident #22) who had a urinary catheter (a tube with retaining balloon passed through the urethra into the bladder to drain urine), and failed to follow professional standards of practice when staff applied Xeroform dressing to one sampled resident’s (Resident #2) foot during the night without a physician’s order. The facility staff failed to ensure each resident’s bowel movements were monitored on a daily basis for three residents (Residents #11, #20, and #22) out of ten sampled residents to prevent constipation/fecal impaction (the presence of hard stool in the rectum found upon digital rectal exam or abdominal x-ray), and to prevent the necessity for staff to manually remove feces. The facility staff failed to provide urinary catheter (a tube with retaining balloon passed through the urethra into the bladder to drain urine) care and appropriately handle the urinary catheter drainage bag for one resident (Resident #20) out of ten sampled residents in a manner to prevent urinary tract infections (UTI). The facility staff failed to transfer three of ten sampled residents (Resident #7, #8, and #11) in a safe manner to prevent the potential for injury; failed to apply physician ordered safety devices consistently to prevent potential accidents for two of ten sampled residents (Resident #8 and #21); failed to complete an elopement assessment upon admission for one of ten sampled residents (Resident #19); and failed to train all staff of the facility’s elopement procedure appropriately and in a timely manner prior to one of ten sampled residents’ (Resident #19’s) elopement from the facility. The facility staff failed to ensure all ducts which penetrate smoke barriers are equipped with a smoke damper (a device in ductwork designed to block the passage of smoke upon fire alarm system activation) that completely closes upon fire alarm system activation and opens after the system is reset, affecting four of eight smoke compartments, residents who reside on the 500 and 200 halls, and residents, staff and visitors in the smoke compartment that included the nurse’s station, lobby, multi-purpose/television room, and the fountain room.
Facility: Swope Ridge Geriatric Center Kansas City, MO 240-Bed Skilled Nursing Facility Date of Notice: August 2009	Owner: City of Kansas City Operator: Care Center of Kansas City Registered Agent: Dorothy Fauntleroy	Legal Action: Uncorrected Class II Notice of Noncompliance
Description: The facility staff failed to obtain physician’s orders to provide treatment for four pressure ulcers for one resident (Resident #25); the facility staff provided treatment to four pressure ulcers without a physician’s order for one resident (Resident #25); and the facility staff documented treatment was performed on three pressure ulcers while the resident was in the hospital for one resident (Resident #25) out of 14 sampled residents.
Facility: Apple Ridge Care Center Waverly, MO 60-Bed Skilled Nursing Facility Date of Notice: September 2009	Owner: Riverview Heights Co. Operator: Waverly #1, Inc. Registered Agent: Clifton Shirell	Legal Action: Uncorrected Class II Notice of Noncompliance
Description: The facility failed to ensure staff maintained the building construction type of Type II (111) in accordance with National Fire Protection Association (NFPA) 19.1.6.2 In the non-sprinklered building, staff did not maintain the integrity of the fire retardant coating of the roof’s undercarriage or maintain one-hour rated ceiling tiles. The deficient practice put all facility residents at risk by not protecting the structural frame of the building from fire.
Facility: Grandview Manor Care Center Grandview, MO 102-Bed Skilled Nursing Facility Date of Notice: September 2009	Owner: Grandview Care Center, Inc. Operator: Same Registered Agent: Hal Juckette	Legal Action: Class I Notice of Noncompliance
Description: The facility failed to prevent recurring wounds which resulted in the development of an avoidable Stage IV (a full thickness of skin and subcutaneous tissue is lost, exposing muscle and/or bone) pressure ulcer for one resident (Resident #3) who was at low risk for developing a pressure ulcer over his/her left ischium (the bottom portion of the hip bone which can be felt under each buttock) by not evaluating and revising interventions such as increasing the frequency of turning and repositioning the resident, evaluating the use of pressure relief devices to manage the resident’s tissue tolerance to pressure, failed to document, monitor, and evaluate the resident’s recurring wounds at least weekly, failed to develop a care plan to prevent recurring wounds, and failed to follow the facility’s own policy to monitor and document for four weeks after a wound healed which compromised the resident’s health status resulting in the resident and his/her family decision for end of life care; failed to develop and implement interventions to prevent the development of four unstageable (full thickness tissue loss in which the base of the ulcer is covered by slough (necrotic (dead) tissue in the process of separating from viable portions of the body which can be yellow, tan, gray, green or brown in color) and/or eschar (thick, leathery, necrotic, devitalized tissue that can be tan, brown or black in color) in the wound bed. Until enough slough and/or eschar is removed to expose the base of the wound, the true depth, and therefore stage, cannot be determined) pressure ulcers for one resident (Resident #16) who was considered low risk for pressure ulcers and entered the facility without any pressure ulcers over his/her coccyx (tail bone), left ischium, and bilateral (both) heels, failed to ensure that the resident was seen by a wound clinic as his/her physician had ordered, failed to ensure that nursing staff performed dressing changes without contaminating the resident’s wound, failed to update the resident’s Braden Scale (a pressure sore risk assessment instrument) for Pressure Ulcer risk as the resident’s condition changed, failed to develop and/or revise the resident’s care plan in a timely manner related to the presence of pressure ulcers and any interventions implemented, and failed to complete a significant change in condition MDS when the resident’s condition declined related to the development of pressure ulcers, increased assistance for ADL’s required, and receiving hospice care; failed to provide physician ordered treatment for pressure ulcers on the buttocks, failed to assess the residents skin upon admission on the Resident Data Collection-Status Upon Admission sheet, failed to assess the pressure ulcers on the buttocks on a weekly basis, failed to follow the care plan for one sampled resident (Resident #13); failed to properly assess a resident who demonstrated a behaviorism of repetitive lower extremity movement for the potential of skin breakdown, failed to put appropriate preventative measures in place to prevent skin breakdown to the heels of one resident (Resident #11); and failed to accurately document the progression of wound development or prevent the recurrence of pressure ulcers to one resident (Resident #12) out of a sampled fifteen residents.
Facility: Thompson Care Center Kansas City, MO 80-Bed Residential Care Facility Date of Notice: October 2009	Owner: Lara, Henry Operator: Jolet II, Inc. Registered Agent: Lawrence Thompson	Legal Action: Class I Notice of Noncompliance
Description: The facility failed to provide Cardiopulmonary Resuscitation to one resident with a full code status who was found by staff to be nonresponsive and not breathing on 8/19/09.
Facility: Woodbine Healthcare & Rehab Center Gladstone, MO 300-Bed Skilled Nursing Facility Date of Notice: October 2009	Owner: Diamond Senior Living, LLC Operator: Woodbine HealthCare, LLC Registered Agent: CSC – Lawyers Incorporating Service Company	Legal Action: Uncorrected Class II Notice of Noncompliance
Description: The facility failed to ensure that staff maintained a safe and effective system of medication distribution and administration. The facility failed to maintain an error rate of less than 5% during administration of medications when the facility had a medication error rate of 6.25%. Nursing staff failed to administer a medicated eye drop for one resident correctly and failed to draw up the correct dose of insulin to administer to a second resident. The facility census was 130 residents.
Facility: Campbell Care Center Kansas City, MO 27-Bed Residential Care Facility Date of Notice: October 2009	Owner: Davis Realty Holdings, LLC Operator: Davis Health Care, Inc. Registered Agent: Robin Martinez	Legal Action: Uncorrected Class II Notice of Noncompliance
Description: The facility failed to obtain approval to operate a second business or license to provide care and protective oversight for medication administration, for five of five residents (Residents #10, #11, #12, #14, and #15) who reside in an independent living residence located next door to the Residential Care Facility (RCF) who were being monitored by RCF staff when administering their insulin, and RCF staff kept inventory of the independent living residents’ medications, blood pressure checks, and kept the residents’ medical records, affecting 26 of 26 residents who currently reside at the RCF.
Facility: The Summit Kansas City, MO 64-Bed Skilled Nursing Facility Date of Notice: October 2009	Owner: JJ Marvine, Inc. Operator: The Summit Registered Agent: N/A	Legal Action: Class I Notice of Noncompliance
Description: A complaint investigation was completed on 09/29/2009. The facility was not in substantial compliance with participation requirements. The facility failed to accurately assess and monitor one resident’s ongoing chronic pain and swollen left hand; keep the physician informed of the swollen hand; notify the physician of the resident’s request to go to the hospital for treatment of his/her swollen hand and failed to provide transportation for the resident to go to the hospital. The resident wheeled him/herself in the wheelchair to the nearest bus stop and took a bus to the hospital. The resident was hospitalized for treatment of his/her hand with intravenous antibiotics and two hand surgeries. Additionally, the facility staff failed to maintain an adequate supply of pain medication in the facility for three residents.
Facility: The Summit Kansas City, MO 64-Bed Skilled Nursing Facility Date of Notice: October 2009	Owner: JJ Marvine, Inc. Operator: The Summit Registered Agent: N/A	Legal Action: Uncorrected Class II Notice of Noncompliance
Description: Facility staff failed to identify an internal pacemaker (an electrical device that can substitute for a defective natural pacemaker and control the beating of the heart by a series of rhythmic electrical discharges) for one resident of 25 sampled residents (Resident #25) who was admitted to the facility with a pacemaker, failed to ensure appropriate and timely pacemaker checks were performed to ensure the pacemaker functioned properly, and failed to develop a comprehensive care plan to include goals and approaches such as when and how pacemaker checks were to be completed, staff monitoring of a resident with a pacemaker, and resident instruction/teaching to report signs/symptoms of any problems.
Facility: Meyer Care Center Higginsville, MO 56-Bed Intermediate Care Facility Date of Notice: October 2009	Owner: George J. & Hilda Meyer Foundation Operator: Same Registered Agent: Not Listed	Legal Action: Class I Notice of Noncompliance
Description: Facility staff failed to develop a comprehensive policy for prevention, treatment, care and documentation of pressure sores (a sore caused by unrelieved pressure resulting in damage of underlying tissue usually located over bony prominences) based on recognized standards of practice; failed to prevent the development of a facility-acquired, avoidable and unstageable pressure sore (a full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown, or black dead tissue) in the wound bed) for one of six sampled residents (Resident #3); failed to develop a care plan that included interventions to relieve pressure after the resident had a change of condition when the resident sustained a left distal femur fracture (a fracture of the long thigh bone between the knee and the hip) resulting in prolonged bedrest for the resident; failed to evaluate the resident’s individual tissue tolerance to determine the frequency of turning and repositioning based on the resident’s individual needs; failed to turn and reposition the resident based on his/her individual needs and tissue tolerance; failed to provide an appropriate wound care treatment for the resident’s pressure sore with slough (dead tissue); and failed to provide wound care treatment in a manner to prevent contamination of the resident’s wound.
Facility: Highland Nursing & Rehab Center Kansas City, MO 162-Bed Skilled Nursing Facility Date of Notice: October 2009	Owner: South Park Partners LP Operator: Highland Nursing and Rehab Center, LLC Registered Agent: Michael Flanagan	Legal Action: Class I Notice of Nonconpliance
Description: The facility failed to have adequate staffing to closely monitor and supervise residents on the second floor secured behavior unit and failed to follow facility instructions and policy to keep the laundry chute room door locked between 5:00 a.m. and 7:00 a.m., on 10/14/09, resulting in one sampled resident (Resident #5) entering the laundry chute room, sliding down the laundry chute to the basement of the facility, resulting in his/her death while inside the laundry chute. The resident was found by laundry personnel in the laundry chute covered by facility dirty linens. Nursing personnel responded and found the resident not breathing and without a heartbeat. Resident #5 was pronounced dead at the hospital at 7:45 a.m. At the time of the incident, all nursing personnel on the second floor secured behavior unit which was a Licensed Practical Nurse (LPN) and two Certified Nurse’s Aides (CNAs) were assisting residents in their rooms, passing medications or doing treatments with other residents and did not observe Resident #5 entering the unlocked laundry chute room. The facility staff also failed to keep the laundry chute room door locked at all times allowing one other sampled resident (Resident #7) of 12 sampled residents, to routinely throw his/her dirty laundry down the laundry chute on his/her own without supervision.
Facility: The Villages of Jackson Creek Independence, MO 120-Bed Skilled Nursing Facility Date of Notice: November 2009	Owner: KCHR Senior Care, LLC Operator: Independence II Operations, LLC Registered Agent: CT Corporation System	Legal Action: Class I Notice of Noncompliance
Description: The facility staff failed to verify one resident’s transfer ability, weight-bearing status and mobility and further failed to provide safe and appropriate transfers to the newly admitted resident with a known history of bilateral knee replacements, a hip replacement, osteoporosis and end stage renal disease (ESRD). On 10/09/2009 staff stood the resident up and attempted to transfer the resident from the bed into a wheelchair resulting in bilateral spiral fractures of his/her femurs and a mid-shaft fracture of his/her right humerus. Facility staff failed to intervene on behalf of the resident.
Facility: Butterfly Haven Kansas City, MO 12-Bed Residential Care Facility Date of Notice: November 2009	Owner: Cameron, Mark & Scarlett Operator: Scarlett Cameron Registered Agent: Not Listed	Legal Action: Uncorrected Class II Notice of Noncompliance
Description: The facility failed to discard expired foods from the refrigerator/freezer units, ensure food was stored and used according to manufacturer’s directions, and ensure food stored in the cabinet and in the refrigerator/freezer units was in sound condition, potentially affecting 12 of 12 residents.
Facility: Grandview Manor Care Center Grandview, MO 102-Bed Skilled Nursing Facility Date of Notice: December 2009	Owner: Grandview Medical Investors, LLC Operator: Grandview Care Center, Inc. Registered Agent: Hal Juckette	Legal Action: Class I Notice of Noncompliance
Description: The facility staff failed to revise and implement a pressure ulcer policy and procedure; failed to prevent, identify, assess, communicate to facility staff and to the resident’s attending physician, document and treat one resident’s facility-acquired, avoidable, unstageable (full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed) pressure ulcer on the resident’s right heel including a failure to complete accurate skin assessments, float the resident’s heels, accurately update the Certified Nursing Assistants’ (CNA) Kardex, update the resident’s care plan to reflect the pressure ulcers, failed to utilize staff with proper wound care training to identify, assess, stage, document, and treat the resident’s pressure ulcer, and failed to remove the resident from a Continuous Passive Motion device (CPM—a treatment method designed to aid in the recovery of joints immediately after trauma or surgery; CPM is carried out by a CPM device, which constantly moves the joint through a controlled range of motion; the exact range is dependent upon the joint, but in most cases the range of motion is increased over time) which was inconsistent with avoiding pressure to the right heel for one sampled resident (Resident #21) who had been readmitted to the facility on 10/5/09 without a pressure ulcer after sustaining a right distal femur (the bone in the leg that extends from the knee to the hip/thigh bone) fracture (a traumatic injury to a bone in which the continuity of the bone tissue is broken) and was in an immobilizer (a device that restricts the movement of the leg) from his/her mid-thigh to his/her mid-calf; failed to document weekly wound assessments with measurements and progression of healing in a second resident’s medical record, failed to obtain a Registered Dietician (RD) consult for the resident, failed to perform a root cause analysis to determine if the resident’s right foot brace was causing pressure to the resident’s right heel before obtaining orders to discontinue the brace, failed to provide pain medication when the resident complained of pain during wound treatment, failed to provide appropriate wound care using principles of infection control to prevent cross-contamination, and failed to obtain from the resident’s physician, prompt and appropriate treatment orders for the second resident (Resident #20) who had an unstageable, facility-acquired right heel pressure ulcer; failed to provide appropriate wound care to a third resident by not removing an old Douderm dressing (an opaque dressing used in medicine to protect wounds from contamination and provide a moist wound-healing environment) and Calmoseptine (a multi-purpose moisture barrier ointment) so the resident’s skin could be assessed for breakdown, failed to provide pain relieving medication to the resident before, during or after wound care, and failed to document weekly wound assessments with measurements and progression of healing in the resident’s medical record for the third resident’s  (Resident #18) Stage II facility-acquired pressure ulcer on the resident’s coccyx (tailbone) and a fourth sampled resident’s (Resident #3) Stage III, facility-acquired left ischium (the bottom portion of the hip bone which can be felt under each buttock) pressure ulcer which deteriorated further to an unstageable pressure ulcer; and failed to fully assess wounds present upon a fifth resident’s admission until three days later, failed to complete a tissue tolerance check for the resident until four days after admission, failed to accurately describe both heel wounds on the resident’s admission care plan, failed to include all wound interventions in the resident’s admission care plan, failed to document the resident’s wounds in his/her Medicare nurse’s notes, failed to document when the resident’s new “ankle” wounds were discovered and failed to document a description of the resident’s new “ankle” wounds in the nurse’s notes, failed to notify the resident’s physician upon discovery of new ankle wounds, failed to document “ankle” wounds on Weekly Skin Integrity Data Collection sheets, failed to discontinue the Calmoseptine treatment to the resident’s buttock as ordered by the physician, failed to maintain the CNA Kardex with the resident’s current wound/preventative skin interventions, failed to accurately document the resident’s treatments on the wound report, failed to discontinue an order for waffle boots on while up in the wheelchair on the resident’s Treatment Administration Record (TAR) until six days after they were discontinued, failed to float the resident’s heels, failed to provide an appropriate treatment to the resident’s unstageable heel wounds by allowing a family member to direct care using an inappropriate treatment method (used lotion), and failed to maintain a current Physician’s Order Sheet (POS) for the fifth resident (Resident #22), of 10 sampled residents.
Facility: Cedars of Liberty, Inc. Liberty, MO 206-Bed Residential Care Facility Date of Notice: December 2009	Owner: Cedars of Liberty, Inc. Operator: Same Registered Agent: James L. Webb	Legal Action: Uncorrected Class II Notice of Noncompliance
Description: A licensure inspection was completed on 06/24/2009. The facility was not in substantial compliance with participation requirements. The facility failed to take corrective action in the area of Fire Safety. Facility staff failed to maintain emergency light inside stairwells: on the first floor, across from a resident room and at the entrance to the women’s dorm.
Facility: Cedars of Liberty, Inc. Liberty, MO 206-Bed Residential Care Facility Date of Notice: December 2009	Owner: Cedars of Liberty, Inc. Operator: Same Registered Agent: James L. Webb	Legal Action: Uncorrected Class II Notice of Noncompliance
Description: At the second revisit, the facility still failed to ensure a safe and effective medication system of medication control and use and failed to ensure all staff had a Missouri certification to pass medication. One nurse aide did not have a valid Missouri certification to administer medication. At the end of one shift, facility staff could not find two bottles of narcotic pain medication and one bottle of anti-anxiety medication that were kept in the overflow medication cart.
Facility: Meyer Care Center Higginsville, MO 56-Bed Intermediate Care Facility Date of Notice: December 2009	Owner: George J & Hilda Meyer Foundation Operator: Same Registered Agent: Not Listed	Legal Action: Uncorrected Class II Notice of Noncompliance
Description: The facility failed to ensure all smoke barrier (a wall designed to resist the passage of smoke extending from outside wall to outside wall and from the floor to the roof deck) penetrations in the attic are filled with an appropriate material having the same fire resistance rating as the surrounding wall. This deficiency has the potential to affect four of four smoke compartments, and all residents, staff and visitors.
Facility: Meyer Care Center Higginsville, MO 56-Bed Intermediate Care Facility Date of Notice: December 2009	Owner: George J & Hilda Meyer Foundation Operator: Same Registered Agent: Not Listed	Legal Action: Uncorrected Class II Notice of Noncompliance
Description: The facility failed to ensure all smoke barrier (a wall designed to resist the passage of smoke extending from outside wall to outside wall and from the floor to the roof deck) penetrations in the attic are filled with an appropriate material having the same fire resistance rating as the surrounding wall. This deficiency has the potential to affect four of four smoke compartments, and all residents, staff and visitors. The facility failed to ensure all penetrations in hazardous area ceilings are sealed with a fire caulking that resists the passage of smoke and is a material that has the same fire resistance rating as the surrounding wall, affecting the room behind the generator room and residents, staff and visitors in one of four smoke compartments.
Facility: Leona House Kansas City, MO 7-Bed Assisted Living Facility Date of Notice: December 2009	Owner: W.H.E. Homes, LLC Operator: Same Registered Agent: Capitol Corporate Services, Inc.	Legal Action: Uncorrected Class II Notice of Noncompliance
Description: At the revisit on 12/02/2009, the facility failed to maintain a negotiable, exterior pathway from the designated southwest exit to either of the two designated emergency gathering points (at the gazebo in the back of the facility or the lawn area in the front of the facility). The facility census was 6.

NORTHEAST REGION
Facility: Big Bend Retreat Slater, MO 60-Bed Intermediate Care Facility Date of Notice: January 2009	Owner: Big Bend Retreat, Inc. Operator: Same Registered Agent: Jason D. Weiker	Legal Action: Class I Notice of Noncompliance In a letter from DHSS: On 1/13/2009, SLCR staff completed a revisit at the facility and determined that the Class I deficiency could be lowered to a Class II.
Description: A complaint investigation was completed on 12/24/08. The facility was not in substantial compliance with participation requirements. The facility failed to notify one resident’s physician of a fall that resulted in a significant change of condition including injury and change in mental status. The resident sustained a subdural hematoma as a result of the fall and died.
Facility: King’s Daughters Home Mexico, MO 33-Bed Intermediate Care Facility Date of Notice: January 2009	Owner: MO Branch King’s Daughters & Sons Operator: MO Branch King’s Daughters Registered Agent: N/A	Legal Action: Class I Notice of Noncompliance In a letter from DHSS: On 1/13/2009, SLCR staff completed a revisit at the facility and determined that the Class I deficiency could be lowered to a Class II.
Description: The facility failed to provide each resident nursing care in accordance with current acceptable nursing practice. When a licensed nurse found one resident unresponsive and without vital signs, the licensed nurse failed to initiate CPR even though there was a current physician order to do so and the resident died. The facility identified one additional resident who was a full code. The facility census was 27.
Facility: Westview Nursing Home Center, MO 60-Bed Skilled Nursing Facility Date of Notice: January 2009	Owner: BKY Properties, Inc. Operator: BKY Healthcare of Center, Inc. Registered Agent: Brandon York	Legal Action: Uncorrected Class II Notice of Noncompliance
Description: An annual survey was completed at the above facility on 10/29/08. The facility was not in substantial compliance with participation requirements. A revisit was completed on 12/29/08. The facility failed to follow physician orders for one resident when staff did not administer a pain medication patch as ordered by the resident’s physician and failed to clarify a physician’s order for another resident.
Facility: Twin Pines Adult Care Center Kirksville, MO 182-Bed Skilled Nursing Facility Date of Notice: January 2009	Owner: Adair County Nursing Home District Operator: Same Registered Agent: Not Listed	Legal Action: Class I Notice of Noncompliance In a letter from DHSS: On 1/30/2009, SLCR staff completed a revisit at the facility and determined that the Class I deficiency could be lowered to a Class II.
Description: A survey and complaint investigation was completed on 01/15/2009. The facility was not in substantial compliance with participation requirements. The facility staff failed to contact two residents’ physicians when one resident had a significant change in condition including low blood pressure, decreased heart rate, cool, clammy skin and diaphoresis, and when the other resident had loose stools, elevated temperature and vomiting. Both residents subsequently died. Also, the facility failed to recognize and assess factors related to one resident’s significant declining condition and implement pertinent interventions consistent with the resident’s condition.
Facility: Crosspointe Residential Care Facility Edina, MO 47-Bed Residential Care Facility Date of Notice: January 2009	Owner: W.L.E. LLC Operator: Same Registered Agent: Dewayne Wellborn	Legal Action: Uncorrected Class II Notice of Noncompliance
Description: A licensure inspection and complaint investigation was completed on 9/25/2008. The facility was not in substantial compliance. A revisit was completed on 01/15/2009. The facility failed to take correction action in the following areas: Administer the 2 stage TB test for employees and residents; Ensure all facility staff completed the Level 1 Medication Aide course; Ensure a safe and effective system of medication control and proper storage of medications; Ensure authorization of the resident or designee to handle resident funds; Maintain receipts of resident’s funds or personal possessions held in trust; Maintain compliance with all applicable laws, rules and regulations. The facility has not been in substantial compliance with regulatory requirements as a result of a complaint investigation completed on 11/20/2006.
Facility: Chariton Park Health Care Center Salisbury, MO 106-Bed Skilled Nursing Facility Date of Notice: February 2009	Owner: Chariton Park Operator: Chariton Park Health Care Center, LLC Registered Agent: Robert Craddick	Legal Action: Uncorrected Class II Notice of Noncompliance In a letter from DHSS: On 8/09/2009, SLCR staff completed a revisit at the facility and determined that the Class I deficiency could be lowered to a Class II.
Description: Based on interview and record review, the facility failed to consult with the resident’s physician in a timely manner about the resident’s significant change in medical condition for one resident (Resident #4) of six residents sampled, when the facility had knowledge the resident had been ill on return to the facility from a leave of absence on 12/26/09. Resident #4 continued to present with complaints and symptoms including diarrhea for several days, nausea, poor appetite, general malaise, a low grade temperature and elevated pulse. The resident was hospitalized on 12/29/08 after his/her return to the facility, and he/she was subsequently diagnosed with fulminate pseudomembranous colitis. The resident underwent an ileostomy and colectomy. The census was 86.
Facility: Southside Towne House Mexico, MO 12-Bed Residential Care Facility Date of Notice: February 2009	Owner: Braun Enterprises Inc. Operator: Same Registered Agent: Sue Braun	Legal Action: Class I Notice of Noncompliance
Description: The facility failed to repair the fire alarm system promptly upon discovery of a problem in the system. The facility failed to immediately notify the department and local fire authority and implement an approved fire watch in accordance with National Fire Protection Association (NFPA) 101, 2000 edition, when the fire alarm system was taken out of service.
Facility: Troy Manor Troy, MO 130-Bed Skilled Nursing Facility Date of Notice: March 2009	Owner: Troy Manor LLC Operator: N & R of Troy, LLC Registered Agent: Charlotte Stutts	Legal Action: Uncorrected Class II Notice of Noncompliance
Description: A survey was completed at the facility on 1/15/2009. The facility was not in substantial compliance with participation requirements. A revisit was completed on 3/11/2009. The facility failed to take corrective action in the following areas: Staff failed to provide repositioning every two hours as directed in the plan of care for one resident. In addition, staff failed to provide the necessary treatment and services to promote healing and prevent new pressure sores from developing for one resident. The facility failed to ensure staff washed their hands when indicated by professional practices during personal care for four residents to prevent the spread of infection.
Facility: Crosspointe Residential Care Facility Edina, MO 47-Bed Residential Care Facility Date of Notice: March 2009	Owner: Not Listed Operator: W.L.E., Inc. Registered Agent: Dewayne Wellborn	Legal Action: Uncorrected Class II Notice of Noncompliance
Description: A licensure and complaint investigation was completed on 01/15/2009. The facility was not in substantial compliance with participations requirements. A revisit was completed on 03/05/2009. The facility failed to: Ensure one resident was physically and cognitively capable of making a path to safety; Install/maintain a complete fire alarm system that automatically transmits to the fire department, dispatching agency or central monitoring company; Ensure fire alarm control panel was integrated into the fire alarm system, all accessible areas of the facility had smoke detectors and manual pull stations within the required distance; Ensure electrical wiring was maintained in good repair and did not present a safety hazard; Ensure water heater was properly installed and maintained; Ensure the range hood suppression system was integrated into the fire alarm system.
Facility: Moore-Pike Nursing Home Bowling Green, MO 64-Bed Skilled Nursing Facility Date of Notice: April 2009	Owner: Pike County Court Operator: Moore-Pike Nursing Home, Inc. Registered Agent: Martha Moore	Legal Action: Uncorrected Class II Notice of Noncompliance
Description: A survey was completed on 02/04/2009. The facility was not in compliance with participation requirements. A revisit was completed on 04/08/2009. The facility failed to take corrective action in the following areas: Ensure staff provided care to meet professional standards of practice to obtain current medication order for one resident, administer medication as ordered by the resident’s physician and notify the resident’s physician when there is a change in status; Ensure residents received the necessary care and services for residents unable to do their own activities of daily living to maintain personal hygiene and prevent body odor; Provide adequate supervision and assistance devices to prevent accidents during transfers; Ensure nursing staff washed their hands when indicated during personal care; Ensure nurse aides were able to demonstrate competency in skills and techniques necessary to care for residents’ needs in a safe and acceptable manner.
Facility: Chariton Park Health Care Center Salisbury, MO 106-Bed Skilled Nursing Facility Date of Notice: April 2009	Owner: Salisbury Associates, LLC Operator: Chariton Park Health Care Center, LLC Registered Agent: Robert J. Craddick	Legal Action: Class I Notice of Noncompliance In a letter from DHSS: On 4/06/2009, SLCR staff completed a revisit at the facility and determined that the Class I deficiency could be lowered to a Class II.
Description: The facility failed to ensure one resident, a resident who had been hospitalized and treated for bilateral pulmonary emboli, received nursing care to include administration of anticoagulant therapy. The facility failed to review all of the resident’s hospital discharge records which showed the resident was to receive anticoagulant therapy at discharge. The facility completed laboratory monitoring of the resident’s coagulation factors for several months, recognizing them as sub therapeutic, without following up with the physician when the facility received no response from the physician to the faxed laboratory data. The facility failed to ensure the resident maintained follow up as ordered with the resident’s hospital attending physician. The resident was transferred to the hospital three months after admission to the facility. The resident expired during the transfer with cause of death noted as massive pulmonary embolism. The census was 87.
Facility: Monroe City Manor Care Center Monroe City, MO 60-Bed Skilled Nursing Facility Date of Notice: April 2009	Owner: Monroe City Manor, Inc. Operator: Same Registered Agent: David Redman	Legal Action: Uncorrected Class II Notice of Noncompliance
Description: A licensure inspection was completed at the facility on 02/06/2009. The facility was not in substantial compliance with participation requirements. A revisit was performed on 03/26/2009. The facility failed to properly assess one resident for the use of a physical restraint and determine the presence of specific medical symptom requiring the use of a restraint; The facility failed to provide the necessary care and services to maintain good grooming and personal hygiene for residents who are dependent on staff to carry out their activities of daily living; The facility failed to ensure a resident with a history of pressure ulcers received treatment and services to prevent new pressure ulcers from developing, promote healing and prevent infection; The facility failed to ensure staff washed their hands after each direct resident contact during personal care to prevent the spread of infection.
Facility: Knox County Nursing Home District Edina, MO 60-Bed Skilled Nursing Facility Date of Notice: April 2009	Owner: Knox County Nursing Home District Operator: Same Registered Agent: Not Listed	Legal Action: Class I Notice of Noncompliance In a letter from DHSS: On 04/30/2009, SLCR staff completed a revisit at the facility and determined that the Class I deficiency could be lowered to a Class II.
Description: A survey was completed on 4/15/09. The facility was not in compliance with participation requirements. The facility staff failed to assess and intervene for one resident who experienced a change in mental status resulting in the resident being hospitalized with diagnosis of severe pneumonia. The resident died 3/15/09. Also, the facility failed to have a system in place to assess and develop interventions to prevent further falls for one resident who staff assessed at high risk for falls. The resident had twelve falls over an eight week period with injuries.
Facility: Maple Grove Lodge Louisiana, MO 90-Bed Skilled Nursing Facility Date of Notice: May 2009	Owner: CCC Maple Grove, LLC Operator: Community Care Center of Louisiana, Inc. Registered Agent: James J. Giaroina	Legal Action: Class I Notice of Noncompliance In a letter from DHSS: On 05/11/2009, SLCR staff completed a revisit at the facility and determined that the Class I deficiency could be lowered to a Class II.
Description: A complaint investigation was completed on 4/24/2009. The facility was not in substantial compliance with participation requirements. The facility failed to ensure the safety of residents transferred with the stand up lift. The facility did not investigate and identify problems with the lift including a defective lift strap. Facility staff continued to transfer residents utilizing the lift and strap after one resident fell from the lift and sustained a significant head injury.
Facility: Lincoln County Nursing & Rehab Troy, MO 90-Bed Skilled Nursing Facility Date of Notice: May 2009	Owner: Troy Real Property, Inc. Operator: N & R of Lincoln County, Inc. Registered Agent: Charlotte Stutts	Legal Action: Uncorrected Class II Notice of Noncompliance
Description: A survey was completed at the facility on 03/17/2009. The facility was not in substantial compliance with participation requirements. A revisit was completed on 05/13/2009. The facility failed to take corrective action in the following areas: To ensure resident funds in excess of $50 were placed in an interest bearing account, separate from the facility operating account; Maintain a surety bond sufficient to ensure protection of resident funds; Develop and implement a plan of care to address a resident admitted with a pressure sore; Provide services to prevent one resident with a history of pressure sores from developing a stage II pressure sore.
Facility: Lynn’s Heritage House, Inc. Louisiana, MO 63353 44-Bed Residential Care Facility Date of Notice: May 2009	Owner: Heritage Estates, LLC Operator: Lynn’s Heritage House, Inc. Registered Agent: Karen Lynn	Legal Action: Class I Notice of Noncompliance
Description: A licensure inspection was completed at the facility on 05/19/2009. The facility was not in substantial compliance with participation requirements. The facility failed to immediately notify the Department of Health and Senior Services (DHSS) and institute an approved fire watch when the fire alarm system was out of service more than four (4) hours in a twenty-four (24) hour period, until the system was returned to full service. The facility fire alarm system went out of service on 05/15/2009. A fire watch was not initiated and facility staff failed to notify DHSS and/or local fire department. Observation on 05/18/2009, showed the fire alarm panel had two signal lights indicating trouble and power failure.
Facility: Countryside Manor Vandalia, MO 18-Bed Assisted Living Facility Date of Notice: June 2009	Owner: Walker, Virginia M. Operator: Same Registered Agent: Not Listed	Legal Action: Uncorrected Class II Notice of Noncompliance
Description: A licensure inspection was completed at the facility on 03/02/2009. The facility was not in substantial compliance with participation requirements. A revisit was completed on 05/28/2009. The facility failed to install heat detectors in the attic as required by National Fire Protection Association (NFPA) 72, 1999 edition, interconnected to the fire alarm system. The facility staff failed to request an extension for the installation of heat detectors in the attic.
Facility: Sunshine Home Care Winfield, MO 45-Bed Residential Care Facility Date of Notice: June 2009	Owner: KROMAL Inc. Operator: Sunshine Home Care, LLC Registered Agent: Shahid Hussain	Legal Action: Uncorrected Class II Notice of Noncompliance
Description: A licensure inspection was completed on 04/22/2009. The facility was not in substantial compliance with participation requirements. A revisit was completed on 06/03/2009. The facility failed to take corrective action in the following areas: To maintain a sprinkler head located in the laundry room free of debris to ensure proper functioning; To ensure hot water temperatures accessible to residents were maintained between 105 to 120 degrees Fahrenheit when temperatures measured 134 degrees in resident rooms; To maintain carpeting that was exposed to water; To maintain records of resident funds and reconciled bank statements.
Facility: Luther Manor Retirement & Nursing Center Hannibal, MO 60-Bed Skilled Nursing Facility Date of Notice: July 2009	Owner: Luther Manor Association Operator: Same Registered Agent: Sharon Moore	Legal Action: Class I Notice of Noncompliance
Description: A complaint investigation was completed on 07/09/2009. The facility was not in substantial compliance with participation requirements. The facility failed to ensure one resident received adequate oversight and supervision to prevent accidents. Facility staff failed to ensure a resident was not left unattended while up in a wheelchair as directed in the plan of care due to a history of falls. The resident fell forward out of the wheelchair after staff left the resident unattended. The resident sustained lacerations to the face and rupture of the globe of the right eye necessitating enucleation (removal of eyeball) of the right eye.
Facility: Towne House Mexico, MO 29-Bed Residential Care Facility Date of Notice: July 2009	Owner: Braun Enterprises Inc. Operator: Same Registered Agent: Sue Braun	Legal Action: Class I Notice of Noncompliance
Description: A complaint investigation was completed on 07/01/2009. The facility was not in substantial compliance with participation requirements. The facility failed to sufficiently monitor one resident to ensure the resident was breathing and in no distress. The resident was last seen alive at 9:00 a.m. on 06/30/09. Staff found the resident in bed, deceased with rigor mortis (stiffness that occurs in dead bodies), at approximately 1:05 p.m. that afternoon. Staff observed the resident in his/her bed several times on 06/30/09 by looking in the resident’s room between 9:00 a.m. and 1:05 p.m., and hollering for the resident to come downstairs for the noon meal/medications, but staff did not check to ensure the resident was breathing or required medical attention.
Facility: Chariton Park Health Care Center Salisbury, MO 120-Bed Skilled Nursing Facility Date of Notice: July 2009	Owner: Salisbury Associates, LLC Operator: Chariton Park Health Care Center, LLC Registered Agent: Robert Craddick	Legal Action: Class I Notice of Noncompliance
Description: A complaint investigation was completed on 07/22/09. The facility was not in substantial compliance with participation requirements. The facility failed to provide adequate oversight and supervision, including visual checks per facility policy to ensure one resident under guardianship and with significant psychiatric and medical diagnoses did not leave the facility without staff knowledge. On 06/29/09 the resident hitchhiked during the night and next day on major state and interstate highways. Facility staff documentation, interviews and written statements showed the resident was present at the facility until 06/30/09 at 8:15 a.m. However the resident was documented in a security camera on 06/29/09 at 10:35 p.m. at a local business.
Facility: Lynns Heritage House, Inc. Louisiana, MO 44-Bed Assisted Living Facility Date of Notice: August 2009	Owner: Not Listed Operator: Lynn’s Heritage House, Inc. Registered Agent: Karen Lynn	Legal Action: Uncorrected Class II Notice of Noncompliance
Description: A licensure inspection was completed on 05/19/2009. The facility was not in compliance with participation requirements. The facility failed to reconcile controlled substance schedule III-V at least weekly for one resident who received a schedule V medication.
Facility: Bristol Manor of Elsberry Elsberry, MO 12-Bed Residential Care Facility Date of Notice: August 2009	Owner: Bristol Care, Inc. Operator: Same Registered Agent: David Furnell	Legal Action: Class I Notice of Noncompliance
Description: A complaint investigation was completed on 07/29/2009. The facility was not in substantial compliance with participation requirements. The facility failed to sufficiently monitor one resident (Resident #1), who had a change in condition, including a significant change in vital signs or to notify the resident’s physician of the change in the resident’s vital signs. The facility failed to contact emergency personnel or initiate cardiopulmonary resuscitation (CPR) when the resident was found unresponsive. The resident subsequently died.
Facility: The Living Center Marshall, MO 99-Bed Skilled Nursing Facility Date of Notice: September 2009	Owner: Not Listed Operator: Fitzgibbon Health Services Registered Agent: Roland Ott	Legal Action: Class I Notice of Noncompliance
Description: A complaint investigation was completed on 08/31/2009. The facility was not in substantial compliance with participation requirements. The facility failed to ensure a resident with a diagnosis of chronic pain and cancer received the necessary services including assessment and monitoring of his/her pain and interventions addressing pain to ensure the resident obtained optimal pain control.
Facility: Moberly Nursing & Rehab Moberly, MO 120-Bed Skilled Facility Date of Notice: September 2009	Owner: Ravenwood Manor Homes, Inc. Operator: N&R of Moberly, Inc. Registered Agent: Charlotte Stutts	Legal Action: Uncorrected Class II Notice of Noncompliance
Description: The facility failed to ensure that one Nurse Aide (NA) working in the facility had completed the Nurse Aide training competency evaluation program within four (4) months of hire.
Facility: Bristol Manor of Palmyra Palmyra, MO 12-Bed Residential Care Facility Date of Notice: September 2009	Owner: Bristol Care, Inc. Operator: Same Registered Agent: David Furnell	Legal Action: Uncorrected Class II Notice of Noncompliance
Description: A licensure inspection was completed on 07/08/2009. The facility was not in substantial compliance with participation requirements. A revisit and complaint investigation was completed on 08/21/2009. The facility failed to ensure an employee, who made a guilty plea related to possession of a controlled substance, did not have access to Schedule II, III and IV controlled substances while working in the facility. The employee also stored a resident’s discontinued Schedule II controlled substance in his/her personal living quarters.
Facility: Putnam County Care Center Unionville, MO 60-Bed Skilled Nursing Facility Date of Notice: September 2009	Owner: Putnam County Nursing Home District Operator: Same Registered Agent: Howard Johnson	Legal Action: Uncorrected Class II Notice of Noncompliance
Description: An annual survey was completed at the facility on 07/08/2009. The facility was not in substantial compliance with participation requirements. The facility failed to take corrective action in the following areas: To provide necessary care and services to maintain good personal hygiene; Ensure a resident having a pressure sore received treatment and services to promote healing and prevent new sores from developing. Staff failed to consistently document assessment of the resident’s skin integrity and existing pressure sore; To provide adequate supervision and assistance devices for one resident who was unable to bear weight and had a physician’s order for use of a mechanical lift for transfers as needed.
Facility: Levering Regional Health Care Center Hannibal, MO 120-Bed Skilled Nursing Facility Date of Notice: October 2009	Owner: Levering Associates, LLC Operator: Levering Regional Health Care Center, LLC Registered Agent: Robert Craddick	Legal Action: Class I Notice of Noncompliance
Description: The facility failed to provide adequate supervision, including visual face checks per facility policy, to ensure two residents (Resident #1 and #2), under guardianship and both with significant psychiatric diagnoses and histories of elopement, did not leave the facility without staff knowledge. Resident #1 kicked open a door on the locked unit where he/she resided, exited the building and hitchhiked to the Branson, Missouri area, (approximately 278 miles away), was gone two days prior to making contact with family and alerting family of his/her whereabouts. Resident #2 left the building through the same broken door and was away approximately one and one half hours before staff located him/her one to two miles from the facility walking along a road. The facility census was 108.

NORTHWEST REGION
Facility: Crestview Home Bethany, MO 24-Bed Residential Care Facility Date of Notice: January 2009	Owner: Bethany Nursing Home Properties, LL Operator: N & R of Crestview, LLC Registered Agent: Charlotte Stutts	Legal Action: Uncorrected Class II Notice of Noncompliance
Description: The facility failed to install/maintain a fire alarm system in accordance with NFPA 72. The facility failed to install the minimum of a 2-hour fire rated separation between different levels of long term care.
Facility: Crestview Home Bethany, MO 160-Bed Skilled Nursing Facility Date of Notice: February 2009	Owner: Bethany Nursing Home Properties, LL Operator: N & R of Crestview, Inc. Registered Agent: Charlotte Stutts	Legal Action: Class I Notice of Noncompliance In a letter from DHSS: On 2/13/2009, SLCR staff completed a revisit at the facility and determined that the Class I deficiency could be lowered to a Class II.
Description: The facility failed to assess, monitor and intervene in a timely manner for one resident after the resident had a fall, mental status/behavior change, bruising of the toes and complaints of pain. On 1/1/09, the facility discharged the resident to the local hospital. The Emergency Room (ER) physician noted the resident had symptoms of hypothermia, urinary tract infection, shock, and a possible fractured toe. The ER physician transferred the resident to a city hospital for further treatment. The resident died on 1/12/09. The facility census was 79.
Facility: Bethany Care Center Bethany, MO 60-Bed Skilled Nursing Facility Date of Notice: February 2009	Owner: N & R of Bethany, Inc. Operator: Same Registered Agent: James C. Lincoln	Legal Action: Class I Notice of Noncompliance In a letter from DHSS: On 2/13/2009, SLCR staff completed a revisit at the facility and determined that the Class I deficiency could be lowered to a Class II.
Description: The facility failed to provide protective oversight and care to one resident to prevent falls with injuries for one resident. The resident fell from bed three times from 11/09-11/24/08. After the third fall, the resident was sent to the emergency room and the physician diagnosed the resident with a fractured left hip and left pelvis. The facility failed to assess possible causative factors of the falls, failed to update the care plan with interventions to prevent falls. Upon return to the facility, a licensed nurse failed to properly transcribe physician orders for the resident’s care and staff failed to implement the physician’s orders to prevent further injury to the fractured hip. The facility census was 36.
Facility: Saxton Care Chateau St. Joseph, MO 69-Bed Nursing Facility Date of Notice: February 2009	Owner: Saxton Care Chateau, Inc. Operator: Chateau Place, Inc. Registered Agent: Glen Muir	Legal Action: Class I Notice of Noncompliance
Description: The facility failed to assure one resident, identified by staff as at risk for elopement, did not leave the building unattended. Staff failed to effectively intervene after the resident displayed significant anger, failed to assure the resident’s alarm bracelet functioned properly, failed to maintain an alarm system to effectively alert staff when a person left the building and failed to follow the facility’s policy and did not complete an elopement assessment. The resident left the building on 1/14/09 at 6:13 p.m., without staff knowledge. Two hours later, the local hospital notified the facility that the resident was at the hospital. At the time the resident left the facility, the resident did not wear a hat, coat or gloves. Temperatures on the day the resident eloped from the facility ranged from 8.1 degrees to 3.9 degrees Fahrenheit.
Facility: Arbor View Healthcare & Rehab Center St. Joseph, MO 120-Bed Skilled Nursing Facility Date of Notice: February 2009	Owner: SPTMIHS Properties Trust Operator: Five Star Quality Care-MO, LLC Registered Agent: CSC-Lawyers Incorporation Service Co.	Legal Action: Class I Notice of Noncompliance In a letter from DHSS: On 2/06/2009, SLCR staff completed a revisit at the facility and determined that the Class I deficiency could be lowered to a Class II.
Description: The facility failed to provide protective oversight to one resident. The facility failed to ensure staff transferred one resident on 01/15/2009 using the appropriate mechanical lift. On 01/16/2009, the resident began to complain of pain in the right arm. X-rays done on 01/16 and 01/17/2009 showed both of the resident’s upper arms were fractured and required placement of double upper extremity immobilizers.
Facility: Gower Convalescent Center, Inc. Gower, MO 82-Bed Skilled Nursing Facility Date of Notice: February 2009	Owner: Gower Convalescent Center, Inc. Operator: Same Registered Agent: Paul Pottier	Legal Action: Uncorrected Class II Notice of Noncompliance
Description: The facility failed to assure staff were effectively trained on the proper use and application of a wound VAC (Vacuum Assisted Closure) Therapy System (a wound management system that promotes wound healing, increased blood supply to the wound, and removes drainage and infectious material from the wound) to promote healing of a Stage IV (a full thickness skin loss with extensive destruction, tissue death, and/or damage to muscle tissue) pressure ulcer for one resident. The facility census was 72.
Facility: Northview Manor Tarkio, MO 95-Bed Skilled Nursing Facility Date of Notice: February 2009	Owner: SPTIHS Properties Trust Operator: Five Star Quality Care-MO, LLC Registered Agent: CSC-Lawyers Incorporation Service Co.	Legal Action: Class I Notice of Noncompliance
Description: The facility failed to assure staff followed their policy when responding to a potential life-threatening situation which directed staff to call 911 and administer cardio-pulmonary resuscitation (CPR) for any resident identified as wanting CPR. On 2/8/09, at 2:14 a.m., Licensed Practical Nurse (LPN) A assessed one resident with no pulse and no respiration. The resident’s medical record directed staff to conduct CPR. LPN A did not call 911 and did not administer CPR. The facility failed to follow their policy to assure all licensed staff maintained current CPR certification. The facility census was 42.
Facility: Abbey Woods St. Joseph, MO 100-Bed Skilled Nursing Facility Date of Notice: March 2009	Owner: Not Listed Operator: Heritage Healthcare Holdings, Inc. Registered Agent: Lowell Fox	Legal Action: Uncorrected Class II Notice of Noncompliance
Description: At the revisit on 02/17/2009, the facility failed to care plan and follow up on notifying the physician for three days when one resident had swelling of the left leg from the foot to above the knee. The facility failed to follow up on contacting the physician when the physician diagnosed the resident had a deep vein thrombosis (DVT-a blood clot deep in a large vein in the lower leg), and failed to obtain orders and treatment in a timely manner. The facility census was 60.
Facility: Eastview Manor Care Center Trenton, MO 90-Bed Skilled Nursing Facility Date of Notice: March 2009	Owner: Eastview Manor, Inc. Operator: Same Registered Agent: David Taff	Legal Action: Class I Notice of Noncompliance
Description: The facility failed to assure staff provided the necessary care and services to one resident. Staff failed to obtain the resident’s ordered laboratory tests, failed to follow the policies and procedures for change in condition and applying oxygen, monitoring the resident with a decreased oxygen saturation and failed to notify the physician in a timely manner when they found the resident at 5:45 a.m., “unresponsive” with an elevated temperature of 101.4 degrees Fahrenheit, decreased oxygen saturation of 74% and low blood pressure of 67/31 millimeters of mercury. The facility census was 55.
Facility: Crestview Home Bethany, MO 24-Bed Residential Care Facility Date of Notice: March 2009	Owner: Bethany Nursing Home Properties, LL Operator: N & R of Crestview Registered Agent: Not Listed	Legal Action: Uncorrected Class II Notice of Noncompliance
Description: The facility failed to maintain the fire alarm in accordance with NFPA 72.
Facility: Arbor View Healthcare & Rehab Center St. Joseph, MO 120-Bed Skilled Nursing Facility Date of Notice: April 2009	Owner: SPTMIHS Properties Trust Operator: Five Star Quality Care-Mo, LLC Registered Agent: CSC – Lawyers Incorporating Service Co.	Legal Action: Uncorrected Class II Notice of Noncompliance
Description: At the second revisit, the facility: Failed to assure staff promoted care in a manner to enhance and maintain residents’ dignity when staff left two residents exposed during care. Failed to assure staff met professional standards when staff did not follow the facility policies and did not follow physician orders. Staff failed to document administered medication, did not provide a treatment as ordered, did not check placement of a feeding tube prior to medication administration and did not develop an interim care plan. Failed to assure staff kept five incontinent residents, dependent on staff, clean and dry, failed to keep one dependent resident’s fingernails clean; failed to keep one dependent resident’s ears clean and free of crusty material; and staff failed to provide oral care to one dependent resident. Failed to assure staff provided care and treatment and failed to follow physician orders to prevent the development of pressure ulcers and to promote healing for two residents. Failed to assure staff accurately assessed and implemented precautions for one resident at risk for falls. The resident fell twice in three days. The second fall resulted in a laceration to the resident’s forehead that required transport to the emergency room. Facility staff also failed to use appropriate transfer techniques when transferring three residents to prevent the potential for injury.
Facility: Hillview Nursing & Rehab Platte City, MO 120-Bed Skilled Nursing Facility Date of Notice: April 2009	Owner: Plattecare Inc. Operator: N & R of Platte City, Inc. Registered Agent: Charlotte Stutts	Legal Action: Uncorrected Class II Notice of Noncompliance
Description: The facility failed to provide a private telephone for residents to make and receive phone calls. This affected all of the facility residents in the behavioral unit (located on the locked unit including floors A, B, and C) of the facility. The facility failed to maintain the resident living environment (floor tile, walls, mop board and sink countertops) clean and/or in good repair. The facility failed to assure staff properly transferred three of seven sampled residents (Residents #8, #20, #31). The facility staff failed to use proper handwashing during care and after removal of soiled gloves for two of six sampled residents (Residents #24, #32) during incontinence care. The facility failed to protect a water line in a interior kitchen wall from freezing. The facility did not maintain floors and walls in the kitchen clean and in good repair. The facility failed to assure staff knew how to extinguish a grease fire in the kitchen. The facility also failed to assure all staff knew the proper procedure for notification of the fire department in case of a fire emergency. This affected all of the facility’s residents. The facility failed to maintain the kitchen serving-window doors that protected exit passageways in the geriatric dining room, to close and/or latch properly.
Facility: Grand River Health Care Chillicothe, MO 60-Bed Skilled Nursing Facility Date of Notice: April 2009	Owner: Noble House of Chillicothe Operator: N & R of Chillicothe, Inc. Registered Agent: Charlotte Stutts	Legal Action: Uncorrected Class II Notice of Noncompliance
Description: At the third revisit completed on 04/07/2009, the facility failed to provide care and services to meet one resident’s needs. The facility failed to notify the physician and seek treatment in a timely manner for one resident who had an acute decline in his/her condition. The resident quit eating and drinking on 03/23/09 and staff did not provide the physician with a complete and accurate description of the resident’s condition and decline. On 03/26/2009, the resident’s guardian requested the facility inform the physician of the resident’s decline. The physician sent the resident to a local hospital. The hospital admission diagnoses were low potassium level, dehydration and decreased appetite. The facility census was 26.
Facility: Shady Lawn Nursing Home Savannah, MO 17-Bed Residential Care Facility Date of Notice: April 2009	Owner: Andrew County Nursing Home District Operator: Progressive Health Care Registered Agent: Jim Lincoln	Legal Action: Class II Notice of Noncompliance In a letter from DHSS: On 05/28/2009, SLCR staff completed a revisit at the facility and determined that the Class I deficiency could be lowered to a Class II.
Description: The facility failed to maintain the fire alarm in accordance with NFPA 72. If two or more levels of care are located in the same building the entire building must meet the most strict construction and fire safety standards.
Facility: Silcott Northside Home St. Joseph, MO 17-Bed Residential Care Facility Date of Notice: April 2009	Owner: Silcott, George & Etta Jane Operator: Not Listed Registered Agent: Not Listed	Legal Action: Uncorrected Class II Notice of Noncompliance
Description: The facility failed to maintain the fire alarm in accordance with NFPA 72. Each floor of the facility shall have at least two (2) unobstructed exits remote from each other. The facility shall maintain smoke barrier separations between floors. Any fault with the fire alarm system shall be corrected promptly upon discovery.
Facility: Woodbine Healthcare & Rehab Center Gladstone, MO 300-Bed Skilled Nursing Facility Date of Notice: May 2009	Owner: Diamond Senior Living LLC Operator: Woodbine HealthCare, LLC Registered Agent: Lawyers Incorporation Service Company	Legal Action: Uncorrected Class II Notice of Noncompliance
Description: At the revisit, the facility failed to correct the following violations: The facility failed to assure proper reconciliation of the resident trust fund accounts by failing to maintain documentation to support reconciliation for the time period of April 2008 through March 2009. The facility failed to assure staff administered medications as the physician ordered. Staff failed to obtain and administer medications for three sampled residents and staff also failed to document they gave all doses of insulin as the physician ordered for two sampled residents. The facility failed to assure staff transferred two residents in a safe manner. Staff did not communicate the appropriate transfer technique to the certified nurse aide (CNA) who transferred one resident. The resident fell from the mechanical lift resulting in a serious injury to his/her leg. Staff did not use the proper size sling during transfer of a second resident placing the resident at risk for injury. The facility failed to obtain an order for continued use of an indwelling catheter for one resident when the resident was admitted from the hospital.
Facility: La Verna Village Nursing Home Savannah, MO 120-Bed Skilled Nursing Facility Date of Notice: May 2009	Owner: PHLV Realty, LLC Operator: PHLV, LLC Registered Agent: CSC – Lawyers Incorporating Service Company	Legal Action: Class I Notice of Noncompliance
Description: The facility staff failed to follow the facility policy and one resident’s care plan when the facility had identified the resident at risk for development of pressure ulcers. Facility staff had identified a “cut” behind one knee on 03/06/2009. Staff failed to routinely assess for any further changes of the resident’s skin. On 03/15/2009, a certified nurse assistant notified the licensed nurse of open areas behind both of the resident’s knees. The license nurse identified the resident had a Stage IV pressure ulcer behind each knee. There was an odor and exposed tendons/ligaments of both Stage IV pressure ulcers. By the first day of the annual inspection on 04/20/2009, the facility had corrected the Class I violation and the deficiency was cited as past non-compliance. The facility census was 103.
Facility: Shady Lawn Nursing Home Savannah, MO 88-Bed Skilled Nursing Facility Date of Notice: May 2009	Owner: Andrew County N H District Operator: Progressive Health Care Group, Inc. Registered Agent: James Lincoln	Legal Action: Class I Notice of Noncompliance In a letter from DHSS: On 05/28/2009, SLCR staff completed a revisit at the facility and determined that the Class I deficiency could be lowered to a Class II.
Description: The facility failed to train staff to properly secure residents’ wheelchairs in the van during transport and failed to assure staff followed the facility policy and procedure and the manufacturer’s instructions for securing wheelchairs in the van for two of two sampled residents (Residents #1 and #2). The facility also failed to assure staff provided timely and appropriate medical treatment for one resident (Resident #1) whose wheelchair fell over backward twice in the van causing a subdural hematoma (bleeding into the space between the brain and the brain cover. If the hematoma puts increased pressure on the brain, slurred speech, impaired balance and dizziness may result and progress to coma and even death), laceration and bruising. The facility census was 50.
Facility: Living Community of St. Joseph St. Joseph, MO 96-Bed Skilled Nursing Facility Date of Notice: June 2009	Owner: Living Community of St. Joseph Operator: Same Registered Agent: CT Corporation System	Legal Action: Uncorrected Class II Notice of Noncompliance
Description: The facility staff failed to provide proper catheter (a sterile tube inserted through the urethra into the bladder to drain urine into a drainage bag) care to prevent the potential for urinary tract infections for two residents. The facility census was 93.
Facility: Village Care Center, Inc. Maryville, MO 50-Bed Skilled Nursing Facility Date of Notice: June 2009	Owner: Village Care Center, Inc. Operator: Same Registered Agent: Edmund Osby	Legal Action: Uncorrected Class II Notice of Noncompliance
Description: The facility failed to: Ensure staff treated residents in a manner to enhance/maintain three residents’ dignity and self respect. Staff failed to provide assistance to three dependent residents who had asked for help with toileting. One resident “wet” him/herself as he/she could not wait for staff to return with help. Ensure staff implemented a program of screening all staff for tuberculosis (TB) when hired. Four staff hired since the inspection and an additional 14 staff had not received step two of the required two step TB test.
Facility: Saxton Woods Care Center St. Joseph, MO 240-Bed Skilled Nursing Facility Date of Notice: June 2009	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 provide documentation to show they conducted smoke detector sensitivity tests on all smoke detectors in resident rooms, the main dining room, the west dining room, the lodge room and the sun room. The facility census was 110 residents.
Facility: Bristol Manor of Smithville Smithville, MO 12-Bed Residential Care Facility Date of Notice: June 2009	Owner: Bristol Care, Inc. Operator: Same Registered Agent: David Furnell	Legal Action: Uncorrected Class II Notice of Noncompliance
Description: The facility failed to ensure the substance used in the basement and in the first floor furnace room to seal the spaces between the foundation and the wood structure, and around the openings for wires and pipes, had a fire rating equivalent to the construction of the surrounding ceiling. This has the potential to affect all residents who reside in the facility.
Facility: Thomas Residential Care Facility St. Joseph, MO 20-Bed Residential Care Facility Date of Notice: June 2009	Owner: Jerry M. Strong & Terry A. Strong Operator: TAS Care, Inc. Registered Agent: Not Listed	Legal Action: Uncorrected Class II Notice of Noncompliance
Description: The facility failed to maintain the fire alarm in accordance with NFPA 72. The facility failed to maintain electrical wiring in good repair.
Facility: Heartland II RCF St. Joseph, MO 52-Bed Residential Care Facility Date of Notice: June 2009	Owner: Barker, Robin L. & Mary C. Operator: Heartland Residential Registered Agent: Not Listed	Legal Action: Class II Notice of Noncompliance
Description: The facility failed to allow inspection of any portion of the building. The facility failed to properly vent dryers to the outside of the building. The facility failed to have inspections and written certifications of the fire alarm. The facility failed to properly maintain the storage of combustible materials.
Facility: Starcare St. Joseph, MO 18-Bed Residential Care Facility Date of Notice: June 2009	Owner: Starcare, LLC Operator: Same Registered Agent: Cheree Corderman	Legal Action: Uncorrected Class II Notice of Noncompliance
Description: At the revisit, the facility had failed to install a complete fire alarm system. The facility did not have a fire alarm panel, strobes, pull stations, or interconnected smoke detectors. This had the potential to affect all residents. The facility census was 14.
Facility: Bristol Manor of Cameron Cameron, MO 12-Bed Residential Care Facility Date of Notice: July 2009	Owner: Bristol Care, Inc. Operator: Same Registered Agent: David Furnell	Legal Action: Uncorrected Class II Notice of Noncompliance
Description: At the revisit on 06/18/2009, the facility had not achieved substantial compliance. The facility failed to: The facility failed to check blood sugar levels and administer insulin as ordered by the physician for one resident with a diagnosis of diabetes. The facility failed to avoid excessive regulation of the residents’ personal lives when the manager changed the smoking rules for staff convenience. The manager changed the scheduled smoking times and had residents sign a form saying they agreed to the change. During interviews, the residents said they felt they had no choice but to sign the form. The manager said she had not considered any alternative plan before or after initiating the change.
Facility: Lexington Care Center Lexington, MO 160-Bed Skilled Nursing Facility Date of Notice: July 2009	Owner: Santa Fe MO Associates, LLC Operator: Lexington Manor Healthcare Group, Inc. Registered Agent: C T Corporation System	Legal Action: Class I Notice of Noncompliance
Description: The facility staff failed to follow their hot water maintenance policy to keep the hot water below 120 degrees (o) Fahrenheit (F); failed to have systems in place to monitor and prevent hot water temperatures ranging from 126.6 degrees Fahrenheit to 164.7 degrees Fahrenheit after one out of five water heaters was repaired; failed to adequately monitor hot water temperatures to prevent hot water from rising to 164.4 degrees Fahrenheit in resident use areas such as the shower rooms, and the sinks in the residents’ rooms and bathrooms which affected all 22 residents who reside on Unit Two and all 17 residents who reside in the Alzheimer’s locked unit; and failed to prevent hot water temperatures from rising to 140 degrees Fahrenheit in resident use areas, shower rooms, and the sinks in the residents’ rooms and bathrooms which affected all 47 residents who reside on the East and West halls on Unit Three. This affected two hot water heaters on four separate halls. Staff failed to prevent one sampled resident (Resident #15) from scalding his/her fingers from the hot water from his/her sink in his/her room and this resident alerted the staff of the hot water after he/she complained to staff of the hot water from his/her sink scalding his/her fingers. This placed all of the 85 residents who currently reside in the facility at risk of serious burn injury, of which some residents have self ambulatory capabilities combined with physical and/or mental illness diagnoses and/or have impaired cognitive decision making skills.
Facility: Shady Lawn Nursing Home Savannah, MO 17-Bed Residential Care Facility Date of Notice: July 2009	Owner: Andrew County Nursing Home District Operator: The Progressive Health Care Group, Inc. Registered Agent: Not Listed	Legal Action: Uncorrected Class II Notice of Noncompliance
Description: The facility failed to promptly correct any fault with the fire alarm system. The facility failed to provide smoke separation within the building. The facility failed to maintain the entire building in accordance with the most stringent construction and fire safety standards for the combined facilities.
Facility: La Verna Village Nursing Home Savannah, MO 120-Bed Skilled Nursing Facility Date of Notice: July 2009	Owner: PHLV Realty LLC Operator: PHLV, LLC Registered Agent: CSC – Lawyers Incorporating Service Co.	Legal Action: Uncorrected Class II Notice of Noncompliance
Description: The facility staff failed to meet professional standards of quality. Staff failed to correctly transcribe physician orders for one resident and failed to obtain physician orders prior to discontinuing a breathing treatment and failed to clarify a physician order prior to discontinuing a blood pressure medication for a second resident. The facility failed to provide appropriate personal hygiene care for three dependent residents who were incontinent. The facility failed to provide proper care and handling of foley catheter bags and tubing to prevent contamination and potential urinary tract infections for four residents. The facility failed to ensure one resident was free of significant medication errors as staff failed to follow physician orders and administer medication as ordered. The facility failed to provide care using acceptable infection control procedures to prevent the spread of infection. Staff did not clean a blood glucose monitoring device after testing each resident when testing multiple residents at a time and did not create a clean surface in each resident’s room to lay the machine on when testing the resident’s blood sugar.
Facility: Livingston Manor Care Center Chillicothe, MO 94-Bed Skilled Nursing Facility Date of Notice: July 2009	Owner: Livingston Manor, Inc. Operator: Same Registered Agent: Hal Juckette	Legal Action: Uncorrected Class II Notice of Noncompliance
Description: At the revisit, the facility failed to refund the resident trust fund account when the facility dispersed funds from resident accounts without authorization or receipts for three residents. The facility also failed to return funds for personal care allowance for one resident. This affected four of nine residents who had money in the resident trust fund. The facility census was 45.
Facility: Shady Lawn Savannah, MO 88-Bed Skilled Nursing Facility Date of Notice: August 2009	Owner: Andrew County Nursing Home District Operator: Progressive Health Care Group, Inc. Registered Agent: James Lincoln	Legal Action: Class I Notice of Noncompliance
Description: The facility failed to provide protective oversight and nursing care consistent with current acceptable nursing practices for one resident. The resident was admitted for rehabilitation following a left above the knee amputation and therapy for prosthesis training. Diagnoses included severe rheumatoid arthritis and muscle spasms. Staff assessed the resident as requiring extensive assistance with bathing, unsteady balance while sitting and with limitation in range of motion on both sides. The facility allowed an unsupervised nurse aide to give the resident a whirlpool bath. The nurse aide left the resident in the whirlpool unattended with no access to a call light and left the facility. Approximately one hour later, night shift staff heard the resident calling for help and removed the resident from the whirlpool bath. The facility census was 41.
Facility: Abbey Woods St. Joseph, MO 100-Bed Skilled Nursing Facility Date of Notice: August 2009	Owner: Not Listed Operator: Heritage Healthcare Holdings, Inc. Registered Agent: Lowell Fox, Jr.	Legal Action: Uncorrected Class II Notice of Noncompliance
Description: The facility failed to follow physician orders to obtain labs and to discontinue medication for one resident; failed to follow-up with the physician for orders to treat a Urinary Tract Infection (UTI) for one resident; failed to transcribe orders correctly and discontinue old orders when the physician changed the orders for one resident; failed to follow physician’s orders to notify the physician when one resident’s blood sugars were over 300 and failed consistently document blood sugar results; and failed to transcribe physician’s orders correctly three residents. (sic) The facility census was 64.
Facility: Heartland II RCF St. Joseph, MO 52-Bed Residential Care Facility Date of Notice: August 2009	Owner: Barker, Robin L. & Mary C Operator: Heartland Residential Care Facility, Inc. Registered Agent: Cindy Barker	Legal Action: Uncorrected Class II Notice of Noncompliance
Description: At the revisit, the facility failed to ensure the facility staff followed professional pharmacy standards and failed to ensure a safe and effective system of medication control and use. Staff failed to label bottles of insulin and injectable hormone medication with the date opened. At least two residents received insulin injections and the manufacturer of the insulin showed a bottle of insulin should be discarded 28 days after opening. One resident received the hormone injections and the manufacturer of the injectable hormone medication showed the medication should be discarded 30 days after opening.
Facility: Sunset Home Maysville, MO 60-Bed Skilled Nursing Facility Date of Notice: August 2009	Owner: DeKalb County Commission Operator: N & R of Maysville Registered Agent: Charlotte Stutts	Legal Action: Class I Notice of Noncompliance
Description: The facility failed to prevent sexual abuse and failed to follow their policy to investigate and prevent further abuse. Staff witnessed Resident #1, an alert male resident with his hands on an unidentified confused female resident’s breast on 12/20/08. On 2/8/09, staff witnessed the resident holding the hand of another unidentified confused female resident while the resident’s shirt was up on one side above her navel. The facility failed to address Resident #1’s behavior and develop a care plan after the 12/20/08 incident and did not develop a care plan to address Resident #1’s behavior until three months after the 2/8/09 incident. The facility failed to assess the effectiveness of Resident #1’s care plan and intervene after staff identified Resident #1 focusing his attention towards another confused female resident (Resident #2). On 6/20/09, staff witnessed Resident #1 in the act of sexual abuse of Resident #2.
Facility: Mockingbird Manor Liberty, MO 16-Bed Residential Care Facility Date of Notice: August 2009	Owner: Sue Ann Rickman Cansler Operator: Rickman Enterprises, LLC Registered Agent: Sue Rickman	Legal Action: Class I Notice of Noncompliance
Description: Based on observation, interviews and record review, the facility staff failed to administer Cardiopulmonary Resuscitation (CPR) to Resident #1, a full code resident, when they found him/her on the floor unresponsive. The resident expired. This affected one resident but had the potential to affect all the residents. All residents were full code.
Facility:: Cameron Nursing & Rehab Cameron, MO 120-Bed Skilled Nursing Facility Date of Notice: August 2009	Owner: Euclid Property LLC Operator: Cameron Nursing & Rehab Center LLC Registered Agent: National Registered Agent	Legal Ation: Class I Notice of Noncompliance
Description: The facility failed to assure licensed nursing staff thoroughly assessed and monitored one resident’s condition after a therapy staff person applied an elastic wrap around the resident’s left small finger on 07/31/2009. The resident already wore a splint to the left hand that staff removed at night. The therapy staff person did not give nursing staff any verbal or written instructions about when to remove the wrap. The wrap remained on the finger until 08/03/2009. The wrap caused circulatory impairment to the finger. On 08/23/2009, the therapy staff person identified the resident’s finger was black from the base of the fingernail to the tip and the remainder of the finger was red. The resident required amputation of the finger due to gangrene. NOTE: At the time of the 08/11/2009 exit, the facility had implemented sufficient corrective action to address the immediacy and the violation was lowered to a Class II.
Facility: Orilla’s Way Grant City, MO 29-Bed Assisted Living Facility Date of Notice: September 2009	Owner: Goff Management, LLC Operator: Same Registered Agent: Not Listed	Legal Action: Uncorrected Class II Notice of Noncompliance
Description: The facility failed to have smoke detectors interconnected to the complete fire alarm system as required by NFPA 72. The facility failed to have a complete fire alarm with automatic transmission as required by NFPA 72. The facility failed to have the sprinkler system interconnected with the fire alarm system.
Facility: Orilla’s Way St. Joseph, MO 8-Bed Residential Care Facility Date of Notice: September 2009	Owner: Goff Management, LLC Operator: Same Registered Agent: Not Listed	Legal Action: Uncorrected Class II Notice of Noncompliance
Description: The facility failed to install smoke detectors interconnected to the complete fire alarm system. The facility failed to install a complete fire alarm system in accordance with the applicable edition of NFPA 72.
Facility: Ashton Court Care & Rehab Center Liberty, MO Date of Notice: September 2009	Owner: Diamond Senior Living LLC Operator: Ashton Court Healthcare, LLC Registered Agent: CSC – Lawyers Incorporating Service Co.	Legal Action: Class I Notice of Noncompliance
Description: An annual survey was completed on 8/18/2009. The facility was not in substantial compliance with participation requirements. The facility failed to prevent development of new pressure ulcers and to provide care and treatment to promote healing of existing pressure ulcers for six residents who had avoidable, facility acquired unstageable/Stage IV pressure ulcers on nine of 12 heels. For one of the six residents, a state surveyor identified an unstageable/Stage IV pressure ulcer on one heel and the facility had no knowledge that the resident had a pressure ulcer. The facility staff failed to develop and implement a system to identify new pressure ulcers, to monitor and document the status of the pressure ulcers, to develop care plans and to implement measures to promote healing.
Facility: Arbor View Healthcare & Rehab Center St. Joseph, MO 120-Bed Skilled Nursing Facility Date of Notice: October 2009	Owner: SPTMIHS Properties Trust Operator: Five Star Quality Care-MO, LLC Registered: CSC-Lawyers Incorporating Service Company	Legal Action: Class I Notice of Noncompliance
Description: The facility failed to ensure nursing staff provided care and services for one resident who developed a facility acquired pressure ulcer of the right shoulder. Licensed nursing staff failed to follow the wound management program; failed to accurately assess, document and monitor the status of the pressure ulcer; failed to implement physician orders for pressure relief and amount of time to be spent in a wheelchair to promote healing of the pressure ulcer; failed to inform the attending physician or the wound care clinic physician of a developing infection of the pressure ulcer; failed to ensure the resident was taken to a wound care clinic appointment; and, failed to assure professional nurses were adequately trained in assessing, documentation and care and failed to revise the care plan with interventions to promote healing of the pressure ulcer. The wound care clinic physician admitted the resident to the hospital on 08/27/09 for treatment of cellulitis and infection of the unstageable pressure ulcer.
Facility: Cedars of Liberty, Inc. Liberty, MO 206-Bed Residential Care Facility Date of Notice: October 2009	Owner: Cedars of Liberty, Inc. Operator: Same Registered Agent: James Webb	Legal Action: Uncorrected Class II Notice of Noncompliance
Description: At the time of the revisit facility staff failed to ensure the facility had a safe and effective system of medication control and use. Nursing staff failed to follow manufacturer instructions and physician orders by not waiting a full minute between administering two puffs of inhalation medication to treat breathing disorders for four of 26 residents who received inhalers. The census was 118 residents.
Facility: Superior Park Excelsior Springs, MO 66-Bed Residential Care Facility Date of Notice: October 2009	Owner: DST, Inc. Operator: Same Registered Agent: Not Listed	Legal Action: Uncorrected Class II Notice of Noncompliance
Description: A licensure inspection was completed on 06/29/2009. The facility was not in substantial compliance with participation requirements. A revisit was completed on 10/07/2009. The facility failed to take corrective actions in the following areas of Fire Safety: Install an approved range hood and approved automatic range hood extinguishing system; To provide an approved one (1) hour rated stairway that is separated from each floor with an exit leading directly outside; Install the required smoke detectors that connect to the fire alarm system; Document the ninety minute annual testing on the emergency lights; Maintain the electrical system in good repair to not present a safety hazard; and Failed to have a current approved boiler and current elevator inspection certification.
Facility: Shady Lawn Nursing Home Savannah, MO 17-Bed Residential Care Facility Date of Notice: December 2009	Owner: Andrew County Nursing Home District Operator: The Progressive Health Care Group, Inc. Registered Agent: Not Listed	Legal Action: Uncorrected Class II Notice of Noncompliance
Description: The facility failed to maintain a two hour fire rated separation between the two levels of care.

SOUTHEAST REGION
Facility: Shady Oaks Retirement Home Poplar Bluff, MO 11-Bed Residential Care Facility Date of Notice: January 2009	Owner: Fears, Dennis & Brook Operator: Brook Fears Registered Agent: Not Listed	Legal Action: Uncorrected Class II Notice of Noncompliance
Description: The facility failed to assure compliance with all applicable laws and regulations by providing care to residents with mental illness diagnoses without a Department of Mental Health (DMH) license. The facility failed to request a criminal background check (CBC) prior to allowing an employee to have contact with the residents.
Facility: Essex Residential Care Essex, MO 50-Bed Assisted Living Facility Date of Notice: January 2009	Owner: Theodore A. Elliott Operator: Same Registered Agent: Not Listed	Legal Action: Class I Notice of Noncompliance In a letter from DHSS: On 2/02/2009, SLCR staff completed a revisit at the facility and determined that the Class I deficiency could be lowered to a Class II.
Description: The facility failed to provide necessary care and services for two residents who received dialysis treatments for renal disease. The facility did not coordinate services with dialysis centers, provide therapeutic diets as ordered, or consistently provide three meals per day for residents.
Facility: Holt Residential Care Bunker, MO 12-Bed Residential Care Facility Date of Notice: February 2009	Owner: Norden, Michael & Donna Operator: Brenda Holt Registered Agent: Not Listed	Legal Action: Class II Notice of Noncompliance
Description: The facility failed to prohibit the use of portable space heaters.
Facility: Oak Ridge Manor Oak Ridge, MO 20-Bed Assisted Living Facility Date of Notice: February 2009	Owner: Sample, Johnnie M. & Tomi Operator: Oak Ridge Manor, Inc. Registered Agent: Not Listed	Legal Action: Class II Notice of Noncompliance
Description: The facility failed to maintain a one (1)-hour separation of hazardous areas. The facility failed to maintain wall and ceiling surfaces of a material or so treated as not to have a flame-spread classification of more than seventy-five (75).
Facility: Partners Residential Care Center, Inc. Poplar Bluff, MO 18-Bed Residential Care Facility Date of Notice: March 2009	Owner: Randolph, Carroll & Karen Operator: Partners Residential Care Registered Agent: Not Listed	Legal Action: Class II Notice of Noncompliance
Description: The facility failed to maintain the fire alarm in accordance with NFPA 72. The facility failed to provide the proper size of fire extinguishers. The facility failed to properly separate hazardous areas. The facility failed to provide sufficient emergency lighting.
Facility: Maple Crest Residential Care Facility Poplar Bluff, MO 20-Bed Residential Care Facility Date of Notice: March 2009	Owner: Maple Crest Residential Care Facility Operator: Douglas Kennedy Registered Agent: Not Listed	Legal Action: Class II Notice of Noncompliance
Description: The facility failed to maintain smoke barrier separations between floors.
Facility: J&J Assisted Living Marble Hill, MO 12-Bed Residential Care Facility Date of Notice: March 2009	Owner: Mary E. Long Living Trust Agreement Operator: J&J Assisted Living, LLC Registered Agent: Barbara Grebing	Legal Action: Uncorrected Class II Notice of Noncompliance
Description: The facility failed to obtain written authorization from the residents in order to hold, safeguard, manage, and account for the residents’ personal funds. The facility failed to exclusively use the personal funds for facility residents only. The facility failed to maintain a bond one and one-half times the average monthly balance for the two residents’ personal funds (account #1 and #2).
Facility: Hilltop Haven Eminence, MO 7-Bed Residential Care Facility Date of Notice: April 2009	Owner: Basham, Sherry Operator: Same Registered Agent: N/A	Legal Action: Uncorrected Class II Notice of Noncompliance
Description: A licensure inspection was completed at the facility on 01/12/2009. The facility was not in compliance with participation requirements. A revisit was completed on 04/07/2009. The facility failed to meet statutory requirements in the area of fire safety when staff installed a new boiler and failed to have the boiler inspected and certified.
Facility: Shepherds View Residential Care Facility Alton, MO 39-Bed Assisted Living Facility Date of Notice: April 2009	Owner: Not Listed Operator: Shepards View, Inc. Registered Agent: Not Listed	Legal Action: Uncorrected Class II Notice of Noncompliance
Description: The facility failed to maintain one (1) hour rated smoke stop partitions.
Facility: The Manor Poplar Bluff, MO 90-Bed Skilled Nursing Facility Date of Notice: April 2009	Owner: Not Listed Operator: Poplar Bluff No. 1, Inc. Registered Agent: Clifton Shirrell	Legal Action: Class I Notice of Noncompliance
Description: The facility failed to ensure hot water temperatures in resident accessible areas (Rooms 4, 8, 9, 30 and 41) did not exceed 120 degrees Fahrenheit. This placed residents at risk of serious burn injury. This condition affects 16 residents with self ambulatory capabilities combined with mental illness/mental retardation diagnoses and/or impaired cognitive decision making skills.
Facility: Golden Livingcenter – New Madrid New Madrid, MO 112-Bed Skilled Nursing Facility Date of Notice: April 2009	Owner: GPH New Madrid Operator: GGNSC New Madrid, LLC Registered Agent: CSC-Lawyers Incorporating Service Company	Legal Action: Class I Notice of Noncompliance
Description: The facility failed to ensure hot water temperatures in resident accessible areas (100 Hall Bathing Room; 200 Hall Bathing Room; 300 Hall Bathing Room; 400 Hall Bathing Room; 400 Hall Dining Room; 400 Hall Barber Shop; and Resident Rooms: 106, 204, 208, and 304) did not exceed 120 degrees Fahrenheit. This placed residents at risk of serious burn injury. This condition affects 56 residents with self ambulatory capabilities combined with mental illness/mental retardation diagnoses and/or impaired cognitive decision making skills. The facility failed to use safe assisted transfer techniques for one resident outside the sample.
Facility: J & J Assisted Living Marble Hill, MO 12-Bed Residential Care Facility Date of Notice: May 2009	Owner: Mary E. Long Living Trust Agreement Operator: J & J Assisted Living, LL Registered Agent: Not Listed	Legal Action: Uncorrected Class II Notice of Noncompliance
Description: The facility failed to maintain smoke barrier separation. The facility was originally notified of the deficiency on 02/11/2009. A revisit was conducted on 04/28/2009.
Facility: J & J Assisted Living Marble Hill, MO 12-Bed Residential Care Facility Date of Notice: June 2009	Owner: Mary E. Long Living Trust Agreement Operator: J & J Assisted Living, LLC Registered Agent: Barbara Grebing	Legal Action: Uncorrected Class II Notice of Noncompliance
Description: The facility failed to manage resident trust funds by allowing ten residents to overspend their accounts; therefore, spending other residents’ money without their authorization. The facility staff also failed to maintain written receipts, with a signature of the resident, to show authorization of the expenditures. The facility staff failed to prevent the commingling of resident funds with facility operating funds for seven residents identified on the facility’s customer balance summary report (accounts receivable aged analysis). The facility failed to provide current accounting and to return the remaining funds to the residents.
Facility: Green Meadows Retirement Home Sikeston, MO 66-Bed Assisted Living Facility Date of Notice: July 2009	Owner: Elliott Real Est. Inc. Operator: Theodore Elliott Registered Agent: Not Listed	Legal Action: Uncorrected Class II Notice of Noncompliance
Description: The facility failed to install components of the fire alarm system as required by NFPA 72, 1999 edition. The facility failed to ensure smoke and heat detectors as required by NFPA 72, 1999 edition. The facility failed to ensure heat detectors were installed as required by NFPA 72, 1999 edition. The facility failed to ensure the flow alarm for the sprinkler system activated the fire alarm as required.
Facility: Jefferson Manor Cape Girardeau, MO 10-Bed Residential Care Facility Date of Notice: August 2009	Owner: Betty McCulley Revok. Trust, Betty M. Operator: Sharon Armour Registered Agent: N/A	Legal Action: Uncorrected Class II Notice of Noncompliance
Description: The facility failed to screen one employee, a level one medication aide, for tuberculosis (TB) within one month prior to starting employment in the facility. The facility failed to bring the resident fund account current each month.
Facility: Shady Oaks Retirement Home Poplar Bluff, MO 11-Bed Residential Care Facility Date of Notice: August 2009	Owner: Fears, Dennis & Brook L. Operator: Brook Fears Registered Agent: Not Listed	Legal Action: Uncorrected Class II Notice of Noncompliance
Description: The facility failed to properly install smoke detectors in accordance with NFPA 72. The facility failed to have a smoke separation barrier between resident use areas and any floor below the resident use areas. The facility failed to have all doors providing separation between floors having a self-closing device attached.
Facility: Green Meadows Retirement Home Sikeston, MO 66-Bed Assisted Living Facility Date of Notice: September 2009	Owner: Elliott Real Estate, Inc. Operator: Theodore Elliott Registered Agent: Not Listed	Legal Action: Uncorrected Class II Notice of Noncompliance
Description: The facility failed to install components of the fire alarm system as required by NFPA 72, 1999 edition. The facility failed to install smoke and heat detectors as required by NFPA 72, 1999 edition. The facility failed to ensure heat detectors were installed as required by NFPA 72, 1999 edition. The facility failed to ensure the flow alarm for the sprinkler system activated the fire alarm as required.

SOUTHWEST REGION
Facility: Truman Healthcare & Rehab Center Lamar, MO 123-Bed Skilled Nursing Facility Date of Notice: January 2009	Owner: Mo-An of Kansas & Missouri LLC Operator: Lamar No. 1, Inc. Registered Agent: Clifton L. Shirrell	Legal Action: Uncorrected Class II Notice of Noncompliance
Description: A survey was completed at the facility on 11/25/08. The facility was not in substantial compliance with participation requirements. A revisit was completed on 12/30/08. The facility failed to comply with the National Electrical Code when there was improper extension cords used to power electrical appliances in five occupied resident rooms.
Facility: Primrose Place Health Care Center Springfield, MO 135-Bed Skilled Nursing Facility Date of Notice: January 2009	Owner: Primrose Place, Inc. Operator: Same Registered Agent: Robert H. Bezanson	Legal Action: Class I Notice of Noncompliance In a letter from DHSS: On 1/02/2009, SLCR staff completed a revisit at the facility and determined that the Class I deficiency could be lowered to a Class II.
Description: An annual survey was completed at the facility on 12/16/08. The facility was not in substantial compliance with participation requirements. The facility staff failed to continually monitor and assess vital signs, mental status and neurological function for one resident who had an unwitnessed fall on 11/13/08 at about 3:45 a.m., and shortly afterwards exhibited mental status changes and high blood pressure. The resident’s condition deteriorated and staff did not monitor or intervene until 6:00 to 6:30 a.m., when the resident was unresponsive. Staff transferred the resident to the hospital where he/she died that same day from an intracerebral hemorrhage (bleeding into the brain).
Facility: Love and Care Boarding Home Joplin, MO 28-Bed Residential Care Facility Date of Notice: January 2009	Owner: Phillips Homer F. Jr. Operator: Same Registered Agent: Not Listed	Legal Action: Uncorrected Class II Notice of Noncompliance
Description: The facility failed to maintain a smoke separation barrier between the resident-use area and the floor below the resident-use area. The facility failed to insure electrical wiring does not present a safety hazard.
Facility: Primrose Place Health Care Center Springfield, MO 135-Bed Skilled Nursing Facility Date of Notice: February 2009	Owner: Primrose Place, Inc. Operator: Same Registered Agent: Robert H. Bezanson	Legal Action: Uncorrected Class II Notice of Noncompliance
Description: Based on observation, interview and record review, the facility failed to follow a physician’s order on 1/13/09 to obtain a urinalysis (UA) for one resident (Resident #25) with a history of urinary tract infections (UTI). Resident #25 showed signs and symptoms of a UTI, which included extreme agitation and hallucinations. The facility obtained the UA on 1/20/09, which showed positive for a UTI that required treatment and resulted in a delay of treatment for at least seven days for one of six sampled residents the facility identified as having a UTI. The facility also failed to ensure the MDS assessment, a federally mandated assessment, was completed accurately to include Resident #25’s history of urinary tract infections. The facility census was 124.
Facility: Neighborhood Senior Residential Care Lebanon, MO 10-Bed Residential Care Facility Date of Notice: February 2009	Owner: Owens, Geneva Ann & Tuell L. Operator: Owens Geneva Ann Registered Agent: Not Listed	Legal Action: Uncorrected Class II Notice of Noncompliance
Description: A licensure inspection was completed on 11/24/2008. The facility was not in substantial compliance with participation requirements. A revisit was completed on 02/03/2009. The facility failed to submit a plan of correction for the inspection completed on 11/24/2008. In addition the facility failed to: Screen one of seven residents for tuberculosis testing as required; Ensure written authorization by a physician to self administer medications; Plan menus in advance and be readily available to staff involved in food preparation; Provide information to residents on advance directives.
Facility: Lawrence County Manor Mt. Vernon, MO 90-Bed Skilled Nursing Facility Date of Notice: February 2009	Owner: Lawrence County Nursing Home District Operator: Same Registered Agent: N/A	Legal Action: Class I Notice of Noncompliance
Description: A complaint investigation was completed on 02/18/2009. The facility was not in compliance with participation requirements. The facility staff failed to follow their abuse/neglect policy and procedure when a staff member left a resident on the toilet and the resident fell sustaining a C1/C2 neck fracture. The staff members working on the resident hall were questioned several times as to how the resident sustained the injury and finally admitted the resident fell. The DON was made aware of the circumstances of the incident and allowed both staff members involved (husband and wife) to finish out their shift before being suspended pending investigation. The facility did implement corrective action by in-servicing staff on the facility abuse/neglect policy and procedures and investigation. The facility made a policy change in hiring of relatives and will not employ spouses or couples with similar living arrangements in the nursing department to work on the same shift.
Facility: Tablerock Healthcare Kimberling City, MO 120-Bed Skilled Nursing Facility Date of Notice: February 2009	Owner: Schluter, Al Operator: Kindered nursing Center East, LLC Registered Agent: C T Corporation System	Legal Action: Class I Notice of Noncompliance
Description: The facility failed to assess, reposition, provide pressure relief on bony prominences, monitor the progress or decline of a pressure ulcer, and implement physician orders for one resident who the facility had identified as being at moderate risk of pressure ulcer development and deteriorated from a Stage II pressure ulcer to a Stage IV pressure ulcer.
Facility: Webb City Health and Rehabilitation Center Webb City, MO 120-Bed Skilled Nursing Facility Date of Notice: February 2009	Owner: Webb City Real Estate, Inc. Operator: Northport Health Services of MO, Inc. Registered Agent: The Corporation Company	Legal Action: Class I Notice of Noncompliance In a letter from DHSS: On 2/17/2009, SLCR staff completed a revisit at the facility and determined that the Class I deficiency could be lowered to a Class II.
Description: The facility failed to develop a plan of care and implement interventions to prevent further falls and injury for one ambulatory resident (Resident #6) who had a history of falls with a previous fracture. The resident had additional falls on 3/14/08 with two fractures of the right foot; on 5/2/08 with a head laceration; on 9/7/08 with a lower right leg fracture; on 10/5/08 without injury; on 10/12/08 with an open fracture (through the skin) of the right ankle that required hospitalization and surgical intervention; and, on 1/7/09 fell out of bed with injuries to the right ankle and subsequent infection of the wound that resulted in a permanent debilitation. The resident is no longer able to walk. The facility census was 93.
Facility: Golden Estate Residential Care Springfield, MO 31-Bed Residential Care Facility Date of Notice: March 2009	Owner: Xia and Mary Residential Care, Inc. Operator: Same Registered Agent: Mary Song	Legal Action: Uncorrected Class II Notice of Noncompliance
Description: A licensure inspection was completed on 01/06/2009. The facility was not in substantial compliance with participation requirements. A revisit was completed on 03/04/2009. The facility failed to maintain comfortable hot water temperatures between 105 degrees and 120 degrees Fahrenheit in three of four resident use bathrooms. Water temperatures in the resident use bathrooms measured between 82 degrees Fahrenheit and 95.1 degrees Fahrenheit.
Facility: Medicalodges Neosho Neosho, MO 114-Bed Skilled Nursing Facility Date of Notice: April 2009	Owner: Newton County Operator: Medicalodges, Inc. Registered Agent: CT Corporation System	Legal Action: Uncorrected Class II Notice of Noncompliance
Description: At the revisit on 03/31/2009, the facility failed to promote care for five residents in a manner that maintained or enhanced the resident’s dignity and respect. The facility also failed to provide appropriate urinary catheter care for one resident with an indwelling urinary catheter, to store medications in a safe and effective manner and to perform wound care according to professional standards to prevent the development and possible transmission of infection for three residents. The facility census was 98.
Facility: Forsyth Care Center Forsyth, MO 120-Bed Skilled Nursing Facility Date of Notice: May 2009	Owner: Forsyth Care Center, Inc. Operator: Forsyth Manor, Inc. Registered Agent: Charlotte Stutts	Legal Action: Class I Notice of Noncompliance In a letter from DHSS: On 05/04/2009, SLCR staff completed a revisit at the facility and determined that the Class I deficiency could be lowered to a Class II.
Description: A survey was completed on 04/20/2009. The facility was not in compliance with participation requirements. The facility staff failed to assess and notify the resident’s physician for follow up and treatment for one resident who exhibited sexually inappropriate behaviors towards two residents with cognitive impairment.
Facility: Neighborhoods at Quail Creek Springfield, MO 112-Bed Skilled Nursing Facility Date of Notice: May 2009	Owner: RH Montgomery Properties, Inc. Operator: Same Registered Agent: Richard Montgomery	Legal Action: Class I Notice of Noncompliance In a letter from DHSS: On 05/04/2009, SLCR staff completed a revisit at the facility and determined that the Class I deficiency could be lowered to a Class II.
Description: An abbreviated survey was completed at the facility on 04/20/2009. The facility was not in substantial compliance with participation requirements. The facility failed to document and report a resident’s fall and initiate neurological checks following the fall which resulted in a delay in evaluation of the resident’s condition. The resident was hospitalized with an intracranial hemorrhage. In addition, the facility staff failed to initiate cardiopulmonary resuscitation on a resident found unresponsive and had a CPR code status.
Facility: West Vue Nursing Center West Plains, MO 120-Bed Skilled Nursing Facility Date of Notice: May 2009	Owner: West Vue, Inc. Operator: Same Registered Agent: Newton Brill	Legal Action: Uncorrected Class II Notice of Noncompliance
Description: A survey was completed on 3/17/2009. The facility was not in substantial compliance with participation requirements. A revisit was completed on 04/30/2009. The facility failed to maintain electrical wiring and equipment in accordance with the National Electrical Code when multi-plug receptacles, extension cords and power strips were improperly used in resident rooms.
Facility: Sarcoxie Nursing Center Sarcoxie, MO 40-Bed Skilled Nursing Facility Date of Notice: May 2009	Owner: Venture Health Holdings, Inc. Operator: Sarcoxie Nursing Center, LLC Registered Agent: Husch Registered Agent, Inc.	Legal Action: Uncorrected Class II Notice of Noncompliance
Description: An annual survey was completed on 02/26/2009. The facility was not in substantial compliance with participation requirements. A revisit was completed on 04/22/2009. The facility failed to take corrected action in the following areas: Investigate injuries of unknown origin in accordance with facility policy; Provide appropriate incontinence care to residents dependent on staff for activities of daily living; Assess one resident’s multiple skin tears and update the plan of care to reflect the resident’s functional status with transfers to prevent recurrent injuries; Provide nutritional assessment by the registered dietician of a resident and follow a specific therapeutic diet based on the needs of the resident who experienced a gradual unplanned weight loss; Document indications for use of an antipsychotic medication and document dose reduction attempts or contraindication of dose reduction; Store medications in a safe and effective manner by having expired medications available for resident use and storing medications that required storage at room temperature in the refrigerator; Establish and maintain an effective infection control program; Provide nurse aide training in accordance with state regulation by using the correct training manual and provide the 16 hour orientation module; Provide the state approved training and orientation to nursing assistants who have worked in the facility for more than four months; Provide the state approved training and orientation to nursing assistants who worked in the facility less than four months; Adequately train staff on how to respond in the event of a fire; Implement a plan to correct care issues through the Quality Assurance process; Provide a continuous hard path to safety from the 200 hall exit.
Facility: Country Living Care Facility Moody, MO 5-Bed Residential Care Facility Date of Notice: May 2009	Owner: Dillard, John Henry & Debra C. Operator: John Henry Dillard Registered Agent: Not Listed	Legal Action: Class II Notice of Noncompliance
Description: The facility failed to maintain the fire alarm in accordance with NFPA 72.
Facility: Woodland Manor Springfield, MO 180-Bed Skilled Nursing Facility Date of Notice: May 2009	Owner: EBG Health Care III, Inc. Operator: Same Registered Agent: Ewing Gourley	Legal Action: Uncorrected Class II Notice of Noncompliance
Description: A survey was completed at the facility on 03/27/2009. The facility was not in substantial compliance with participation requirements. A revisit was completed on 05/15/2009. The facility failed to appropriately store medications at the proper temperature and ensure staff followed manufacturer’s guidelines for the use of insulin. Facility staff stored a medication used for the treatment of nausea and vomiting in the refrigerator at 38 degrees Fahrenheit (F) when the manufacturer recommended the medication be stored at room temperature (66 to 77 degrees F.). In addition, staff administered residents’ insulin after the vial had been opened past the manufacturer’s recommended 28 days.
Facility: Neighborhood Senior Residential Home Lebanon, MO 10-Bed Residential Care Facility Date of Notice: June 2009	Owner: Owens, Geneva Ann & Tuell L. Operator: Geneva Ann Owens Registered Agent: Not Listed	Legal Action: Class II Notice of Noncompliance
Description: The facility failed to maintain the fire alarm in accordance with NFPA 72. The facility failed to maintain smoke stop partitions.
Facility: Christian Health Care, Hermitage Hermitage, MO 120-Bed Skilled Nursing Facility Date of Notice: June 2009	Owner: CM Hermitage Park, LLC Operator: Christian Health Care of Hermitage, Inc. Registered Agent: Pete Stayton	Legal Action: Class I Notice of Noncompliance
Description: An annual survey was completed at the facility on 05/22/2009. The facility was not in substantial compliance with participation requirements. The facility failed to ensure the resident environment remained free of accident hazards when hot water temperatures exceeded the appropriate temperature range of 105 to 120 degrees Fahrenheit (F) in resident rooms and shower rooms. Facility staff failed to adequately monitor hot water temperatures and promptly repair the water heating system (for nearly a year) when staff knowingly altered the system to bypass the holding tank resulting in excessive hot water temperature up to 148 degrees F.
Facility: The Gardens Springfield, MO 147-Bed Assisted Living Facility Date of Notice: July 2009	Owner: Not Listed Operator: Bethesda Foundation Registered Agent: Not Listed	Legal Action: Uncorrected Class II Notice of Noncompliance
Description: The facility failed to correctly install components of the fire alarm system as required by NFPA 72.
Facility: Golden Estate Residential Care Springfield, MO 31-Bed Residential Care Facility Date of Notice: July 2009	Owner: XIA and Mary Residential Care, Inc. Operator: Same Registered Agent: Not Listed	Legal Action: Class II Notice of Noncompliance
Description: The facility failed to have smoke detectors properly installed. The facility to maintain records of fire alarm tests, inspections, and certifications.
Facility: Neighborhood Senior Residential House Lebanon, MO 10-Bed Residential Care Facility Date of Notice: July 2009	Owner: Owens, Geneva Ann & Tuell L. Operator: Geneva Ann Owens Registered Agent: Not Listed	Legal Action: Uncorrected Class II Notice of Noncompliance
Description: The facility failed to request and document an annual consultation from the local fire department. The facility failed to ensure smoke detectors were interconnected to the complete fire alarm as required by NFPA 72. The facility failed to provide smoke stop partitions to prevent the transfer of toxic (sic) and fumes in the event of a fire.
Facility: Lake’s Residential Care Houston, MO 12-Bed Residential Care Facility Date of Notice: July 2009	Owner: Lake, Aloysius & Irma Operator: Aloysius Lake Registered Agent: Not Listed	Legal Action: Uncorrected Class II Notice of Noncompliance
Description: The facility failed to ensure smoke detectors were interconnected to a complete fire alarm as required by NFPA 72.
Facility: Appleton City Manor Appleton City, MO 60-Bed Skilled Nursing Facility Date of Notice: August 2009	Owner: Appleton City Manor, LLC Operator: Same Registered Agent: Marcus Reed	Legal Action: Class I Notice of Noncompliance
Description: A complaint investigation was completed on 08/04/2009. The facility was not in substantial compliance with participation requirements. The facility failed to use appropriate technique and the correct sling for the safe and effective operation of a mechanical lift when transferring one resident from a wheelchair to bed. The resident fell out of the sling and sustained a head injury requiring hospitalization. Seven residents at the facility required the use of the mechanical lift for transfers.
Facility: Red Rose Health & Rehab Center Cassville, MO 90-Bed Skilled Nursing Facility Date of Notice: August 2009	Owner: Cassville Real Estate, Inc. Operator: KMJ Enterprises Cassville, LLC Registered Agent: Jim Norrid	Legal Action: Class I Notice of Noncompliance
Description: The facility failed to ensure the automatic sprinkler system is installed in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems, to provide complete coverage for all portions of the building. Five sprinkler heads protecting three of five resident corridors (exit access areas) were missing. Two resident halls had sprinkler heads missing that protected both the exit doors and the doors separating the smoke compartments on those halls. One sprinkler head was missing that protected the exit door on a third hall. Outside companies had inspected the facility’s sprinkler system on 12/22/08, and recommended sprinkler heads be flushed or replaced due to significant rust and debris. Another outside company completed an inspection of the sprinkler system on 4/17/09, and reported the system was abnormal because the sprinkler water-seal assembly did not release at the applied test water pressure to discharge the water. The facility did not take corrective action to repair and maintain their sprinkler system for at least seven months.
Facility: Dallas County Care Center Buffalo, MO 60-Bed Skilled Nursing Facility Date of Notice: August 2009	Owner: Deaconess Long Term Care of Missouri, Inc. Operator: Same Registered Agent: The Corporation Co.	Legal Action: Class I Notice of Noncompliance
Description: A survey was completed at the facility on 07/20/2009. The facility was not in substantial compliance with participation requirements. The facility failed to ensure that a resident who enters the facility without pressure sores does not develop pressure sores unless the individuals clinical condition demonstrates they were unavoidable. The facility failed to assess, monitor and provide the necessary services to prevent one resident from developing a fluid filled blister due to improper fitting shoes. The pressure sore deteriorated to a Stage III with a 2 centimeter (cm) by 2 cm area that was unstageable. The resident’s foot was red and painful with odor present and a small amount of drainage. Facility staff failed to notify the resident’s physician timely to obtain appropriate treatment and assure the resident had appropriate footwear.
Facility: Sarcoxie Nursing Center Sarcoxie, MO 40-Bed Skilled Nursing Facility Date of Notice: September 2009	Owner : Venture Health Holdings Inc. Operator: Sarcoxie Nursing Center, LLC Registered Agent: Husch Registered Agent, Inc.	Legal Action: Class I Notice of Noncompliance
Description: A complaint investigation was completed at the facility on 08/25/2009. The facility was not in substantial compliance with participation requirements. The facility failed to implement an accurate and efficient system for identification of each residents’ code status. In addition the facility failed to educate and inform residents regarding end of life care and choices and did not have physician orders for residents’ code status.
Facility: Manorcare Health Services Springfield, MO 40-Bed Assisted Living Facility Date of Notice: October 2009	Owner: HCR Manorcare Properties, LLC Operator:  C T Corporation System Registered Agent: Not Listed	Legal Action: Uncorrected Class II Notice of Noncompliance
Description: The facility failed to insure separation between the two facilities was a one (1) hour fire rated separation.
Facility: Truman Healthcare & Rehab Center Lamar, MO 123-Bed Skilled Nursing Facility Date of Notice: December 2009	Owner: Mo-An of Kansas & Missouri LLC Operator: Lamar No. 1, Inc. Registered Agent: Clifton Shirrell	Legal Action: Class I Notice of Noncompliance
Description: A survey was completed at the above facility on 11/17/2009. The facility was not in substantial compliance with participation requirements. The facility failed to provide adequate supervision and assistance devices to prevent accidents for four residents assessed as a high risk for falls, who had a recent history of falls with serious injuries which included the following: The resident had multiple falls resulting in a closed head injury, multiple hematomas, cuts to inside of mouth and facial bruising; Resident had multiple injuries to the head including hemorrhaging, a hematoma, multiple lacerations one of which required staples to the head and a fractured hip; The resident experienced multiple falls resulting in skin tears, lacerations, hematomas and head injury; The resident had multiple falls resulting in multiple skin tears, hematomas and head injury.
Facility: Licking Residential Care Licking, MO 34-Bed Residential Care Facility Date of Notice: December 2009	Owner: Licking Residential Care, LLC Operator: Community Residence, Inc. Registered Agent: Not Listed	Legal Action: Uncorrected Class II Notice of Noncompliance
Description: The facility failed to have a properly installed fire alarm system in accordance with NFPA72
Facility: Tablerock Healthcare Kimberling City, MO 120-Bed Skilled Nursing Facility Date of Notice: December 2009	Owner: Schluter, Al Operator: Kindred Nursing Centers East, LLC Registered Agent: C T Corporation System	Legal Action: Class I Notice of Noncompliance
Description: A complaint investigation was completed at the facility on 11/17/2009. The facility was not in substantial compliance with participation requirements. The facility failed to provide protective oversight for one resident assessed by the facility as cognitively impaired, at risk for falls, and who had a history of wandering. The facility staff failed to: Place the resident on a supervised locked unit as ordered by the physician on 10/09/09; Initiate and conduct a facility and facility grounds search when the staff identified the resident as missing; Notify the administrator, director of nursing and proper authorities in a timely manner as directed by the facility’s policy and procedure for missing/eloped residents; Ensure staff were informed of the location of the keys used to access locked facility doors after hours.
Facility: West Vue Nursing & Rehab West Plains, MO 120-Bed Skilled Nursing Facility Date of Notice: December 2009	Owner: West Vue, Inc. Operator: Same Registered Agent: Newton Brill	Legal Action: Class I Notice of Noncompliance
Description: The facility failed to provide continuous oversight and supervision to three residents (Residents #1, #2, and #3) who wore Wander Guard alarms (alert facility staff when a resident makes an unauthorized attempt to leave the facility’s premises (elopement)). The facility failed to have a system in place for monitoring residents who were at risk for elopement. The facility failed to have a documented plan in place for each resident related to their elopement risk. A family member returned Resident #1 to the facility after finding the resident in the facility’s parking lot. Employees from a nearby business (0.2 miles from the entrance of the facility to the parking lot of the business) returned Resident #2 to the facility after finding the resident in the parking lot of the business. The resident told the employees of the business he/she had gone too far and couldn’t get back.. A staff member saw Resident #3 get into a vehicle he/she did not recognize and did not report the incident to the facility administration. The facility failed to keep consistent documentation of the resident’s location and maintain the resident sign out sheet or document in the nurses’ notes the resident’s location. The facility census was 117.

ST. LOUIS REGION
Facility: Northgate Park Nursing Home Florissant, MO 158-Bed Skilled Nursing Facility Date of Notice: January 2009	Owner: LaSalle Real Estate Assets LLC Operator: FLO-GP Leasing Co., LLC Registered Agent: Mayer S. Klein	Legal Action: Class I Notice of Noncompliance In a letter from DHSS: On 1/16/2009, SLCR staff completed a revisit at the facility and determined that the Class I deficiency could be lowered to a Class II.
Description: The facility failed to adequately supervise one resident, which resulted in the resident’s death. Facility staff did not observe the resident for over four hours and did not conduct routine rounds on the resident during two shifts. Staff found the resident during the night shift, outdoors on a patio in cold, wet weather. The resident died with hypothermia.
Facility: Chateau Ann Marie St. Louis, MO 20-Bed Residential Care Facility Date of Notice: January 2009	Owner: Henlon, Warren L. Operator: Chateau Ann Marie, LLC Registered Agent: Karen Michelle Reiter	Legal Action: Uncorrected Class II Notice of Noncompliance
Description: The facility failed to insure that the exit signs were illuminated by both normal and emergency lighting. The facility failed to maintain documentation and certification that the fire alarm system was tested and inspected annually by an approved qualified service representative. The facility failed to insure that the doors between floors that had self closing devices remain closed. The facility failed to insure that the battery back up system for the emergency light was operational. The facility failed to enforce the regulation that only one appliance can be connected to one extension cord and only two appliances may be served by one duplex receptacle.
Facility: Arbor Place of Festus, Inc. Festus, MO 81-Bed Skilled Nursing Facility Date of Notice: January 2009	Owner: Arbor Health Properties, Inc. Operator: Arbor Place of Festus, Inc. Registered Agent: John M. Sells	Legal Action: Class I Notice of Noncompliance In a letter from DHSS: On 1/05/2009, SLCR staff completed a revisit at the facility and determined that the Class I deficiency could be lowered to a Class II.
Description: The facility failed to provide oversight and supervision to protect residents from abuse, accidents, and injury. Out of 24 sampled residents, the facility failed to protect a resident from sexual abuse, provide supervision and interventions to prevent a fall for one resident, reduce the risk of incidence of resident to resident confrontation for four residents, reduce the risk of incidence of resident to resident physical abuse for two residents, prevent access of non-prescribed medications for two residents, and prevent the incidence of ingestion of non-food substances for one resident.
Facility: Arbor Place of Festus Festus, MO 81-Bed Skilled Nursing Facility Date of Notice: February 2009	Owner: Arbor Health Properties, Inc. Operator: Arbor Place of Festus, Inc. Registered Agent: John M. Sells	Legal Action: Uncorrected Class II Notice of Noncompliance
Description: The facility staff failed to maintain resident rooms at comfortable room temperatures for the residents. The facility failed to update appropriate interventions after one resident hit two other residents. The facility failed to serve food that was palatable with cold foods at or below 41 degrees Fahrenheit (F) and hot foods at 140 degrees (F) or above for two of two observed meals.
Facility: Ava Place St. Louis, MO 40-Bed Residential Care Facility Date of Notice: February 2009	Owner: Deaconess Long Term Care Operator: Same Registered Agent: C T Corporation	Legal Action: Class II Notice of Noncompliance
Description: Based on observation and interview, the facility failed to ensure that the complete fire alarm system was in accordance with the National Fire Protection Association (NFPA) 72. The census was 25.
Facility: Cedars at the JCA Chesterfield, MO 230-Bed Skilled Nursing Facility Date of Notice: February 2009	Owner: Jewish Center for Aged Operator: Same Registered Agent: Not Listed	Legal action: Uncorrected Class II Notice of Noncompliance
Description: The facility failed to administer medications per physician’s orders. Ten of eleven sampled residents had missing doses of medications or missing treatments. The facility failed to appropriately monitor and assess one of eleven sampled residents after a fall and failed to monitor and assess one of eleven sampled residents for pain.
Facility: Superior Residential Care St. Louis, MO 30-Bed Residential Care Facility Date of Notice: February 2009	Owner: Klotz Real Estate LLC Operator: Superior Residential Care, LLC Registered Agent: Kenneth Klotz	Legal Action: Uncorrected Class II Notice of Noncompliance
Description: The Administrator failed to devote sufficient time and attention to the management of the facility as is necessary for the health, safety, and welfare of the residents. The facility failed to develop a safe and effective system of medication administration, for three of ten expanded residents who administered inhalers improperly; and for four of ten expanded residents who did not receive medications as ordered by the physician.
Facility: Saddler Residential Care Facility St. Louis, MO 22-Bed Assisted Living Facility Date of Notice: February 2009	Owner: Saddler, LaTerryl Operator: Saddler Residential Care Facility, Inc. Registered Agent: LaTerryl Saddler-Chavis	Legal Action: Uncorrected Class II Notice of Noncompliance
Description: The facility failed to supply curtains and drapes treated to be flame-resistant.
Facility: Creve Coeur Manor St. Louis, MO 149-Bed Skilled Nursing Facility Date of Notice: February 2009	Owner: Creve Coeur Place, LLC Operator: Creve Coeur Manor, LLC Registered Agent: Sharo Shirshekan	Legal Action: Class I Notice of Noncompliance
Description: The facility staff failed to maintain exit doors to be free from obstructions such as snow and ice. These impediments prevented full and instant use of the exit doors affecting all occupants of the facility in the event of an emergency requiring an evacuation. The resident census was 52. (Note: At the time of the exit conference on 1/29/09, the removal of the snow accumulations allowing the exit doors to readily open and use of cleared pathways, abated the imminent danger. The facility had not completed inservice education for all maintenance staff to ensure the designated exits remained unobstructed. The deficiency was lowered to a Class II. This statement does not denote that the facility has complied with Sectiom 198.026.1 RSMo regarding prompt remedial action for a violation of a Class I standard.
Facility: Newstead Place St. Louis, MO 20-Bed Residential Care Facility Date of Notice: February 2009	Owner: Center Housing II Inc. Operator: Independence Center Registered Agent: C T Corporation	Legal Action: Uncorrected Class II Notice of Noncompliance
Description: The facility failed to ensure that a visual or a tactile alarm was installed for a hearing impaired occupant.
Facility: Chateau Ann Marie St. Louis, MO 20-Bed Residential Care Facility Date of Notice: February 2009	Owner: Henlon, Warren L. Operator: Chateau Ann Marie, LLC Registered Agent: Karen Reiter	Legal Action: Uncorrected Class II Notice of Noncompliance
Description: The facility failed to screen residents and staff for tuberculosis. The deficiency was originally cited on 09/10/2008 and found to be uncorrected on 12/01/2008 and 01/30/2009.
Facility: St. Johns Place St. Louis, MO 94-Bed Skilled Nursing Facility Date of Notice: March 2009	Owner: Bentley Development Corp. Operator: St. John’s Place, Inc. Registered Agent: Jerome Kraus	Legal Action: Class I Notice of Noncompliance
Description: The facility failed to follow the resident’s health care directive and the physician’s directive to provide cardiopulmonary resuscitation (CPR) for one resident (Resident #1) of three sampled residents, failed to have a policy compatible with providing CPR whenever needed, and failed to have CPR certified staff in the facility at all times. This potentially could affect the forty-four full code status residents in the facility. Resident #1 was found unresponsive and was a full code and staff did not provide CPR. Resident #1 died.
Facility: Sabbath Manor St. Louis, MO 64-Bed Residential Care Facility Date of Notice: March 2009	Owner: SADAF, LLC Operator: Frasat, LLC Registerd Agent: Bilkiss Cahudhry	Legal Action: Uncorrected Class II Notice of Noncompliance
Description: The facility failed to ensure staff administered medication according to the physician’s order for one resident. The facility failed to ensure a criminal background check (CBC) and a check of the employee disqualification list (EDL) was completed prior to allowing staff to have contact with residents for two of two sampled employees.
Facility: Desmet Retirement Community Florissant, MO 90-Bed Residential Care Facility Date of Notice: April 2009	Owner: Desmet RHF Housing, Inc. Operator: Same Registered Agent: National Registered Agents, Inc.	Legal Action: Class I Notice of Noncompliance In a letter from DHSS: On 04/29/2009, SLCR staff completed a revisit at the facility and determined that the Class I deficiency could be lowered to a Class II.
Description: The facility failed to properly identify and assess a resident who required a higher level of care due to severe occurrence of diarrhea and a weakened condition. The resident was readmitted to the facility from skilled nursing and continued to have diarrhea. Staff did not notify the resident’s physician of the resident’s change in condition. The resident was sent to the hospital after staff found the resident with blue colored extremities and had an oxygen saturation level at 66% (normal range 95% to 100%). The resident expired in the hospital the next day. The facility failed to meet the needs for three sampled residents with diarrhea and falls. One resident who experienced diarrhea for several days and a weakened condition was sent to the hospital and expired. In addition, the facility failed to follow physician’s orders for two additional sampled residents.
Facility: Life Care Center of St. Louis St. Louis, MO 100-Bed Skilled Nursing Facility Date of Notice: April 2009	Owner: Not Listed Operator: C.M.C. Extended Care Center, Inc. Registered Agent: CT Corporation System	Legal Action: Uncorrected Class II Notice of Noncompliance
Description: The facility staff failed to assess for the presence of pain and provide effective pain management for three residents. The facility failed to provide necessary treatment to promote healing, including clean wound care technique and adequate pain management for one resident.
Facility: Arbor Place of Festus Festus, MO 81-Bed Skilled Nursing Facility Date of Notice: April 2009	Owner: Arbor Health Properties, Inc. Operator: Arbor Place of Festus, Inc. Registered Agent: John Sells	Legal Action: Class I Notice of Noncompliance
Description: The facility failed to provide prompt intervention and adequate assessment for two residents with a change in condition following head injuries. One resident was hospitalized with a subdural hematoma and multiple facial fractures and the other resident had a hematoma and a facial abrasion.
Facility: Crestwood Health Care Center, LLC Florissant, MO Date of Notice: April 2009	Owner: Florissant Property, LLC Operator: Crestwood Health Care Center, LLC Registered Agent: Robert Craddick	Legal Action: Uncorrected Class II Notice of Noncompliance
Description: The facility failed to prevent the commingling of resident funds with facility operating funds for 54 residents identified on the facility’s Interim Aged Analysis Report. The facility failed to maintain written authorizations for residents’ expenditures. This affected three of five sampled residents (Residents #33, #53 and #77).
Facility: Cori Manor Healthcare & Rehab Center Fenton, MO 124-Bed Skilled Nursing Facility Date of Notice: April 2009	Owner: Cori Manor Properties, LLC Operator: Cori Manor Healthcare & Rehab Center, LLC Registered Agent: Mark Rubin	Legal Action: Class I Notice of Noncompliance
Description: The facility failed to ensure hot water temperatures in resident accessible areas did not exceed 120 degrees Fahrenheit. This condition affected two of 21 residents reviewed and three residents outside the sample.
Facility: Lutheran Senior Services at Richmond Terrace St. Louis, MO 99-Bed Residential Care Facility Date of Notice: May 2009	Owner: Lutheran Senior Services Operator: Same Registered Agent: Not Listed	Legal Action: Uncorrected Class II Notice of Noncompliance
Description: The facility failed to maintain the fire alarm in accordance with NFPA 72. The facility failed to maintain the sprinkler system in accordance with NFPA 13.
Facility: Mark Twain Manor Bridgeton, MO 120-Bed Skilled Nursing Facility Date of Notice: May 2009	Owner: MTH Associates Limited Partnership Operator: N & R of Poplar Bluff, Inc. Registered Agent: Charlotte Stutts	Legal Action: Uncorrected Class II Notice of Noncompliance
Description: The facility failed to ensure staff provided services to promote the healing of pressure sores and to prevent the development of new pressure sores for one of 13 sampled residents by the failure to periodically reposition the resident and the failure to place the resident on a pressure relief device when seated in the chair. The facility failed to ensure staff provided residents adequate assistance devices and supervision during transfers between surfaces to prevent accidental injuries for four of 13 sampled residents.
Facility: Whispering Oaks Wildwood, MO 70-Bed Residential Care Facility Date of Notice: May 2009	Owner: Whispering Oaks Residential Care Facility LLC Operator: Whispering Oaks RCF Management Company, Inc. Registered Agent: Naren Chaganti	Legal Action: Uncorrected Class II Notice of Noncompliance
Description: The facility failed to ensure an electrical inspection was completed every two years. The facility failed to provide a licensed Administrator who was responsible for the management and operations of the facility. The Owner/Administrator failed to ensure the facility followed all rules and regulations by failure to provide an administrator, ensure inspections were completed, the well drinking water was tested, and to ensure residents were provided with oversight and appropriate care. The facility failed to have sufficient staff on duty during the day and evening shifts to meet the staffing requirements for fire safety for four of ten day shifts reviewed and six of ten evening shifts reviewed. The facility failed to follow physician’s orders for four of five sampled residents who did not receive intramuscular injections as ordered. The facility failed to request a criminal background check (CBC) prior to hire, for two of three sampled employees and for one of two expanded sampled employees.
Facility: Hopewell Group Home St. Louis, MO 12-Bed Residential Care Facility Date of Notice: May 2009	Owner: Holmes Annquienette D. Operator: Hopewell Center Registered Agent: Not Listed	Legal Action: Class II Notice of Noncompliance
Description: The facility failed to maintain the fire alarm in accordance with NFPA 101.
Facility: Green Valley Nursing & Rehab St. Louis, MO 63138 150-Bed Skilled Nursing Facility Date of Notice: May 2009	Owner: Green Valley Real Property LLC Operator: Green Valley Nursing & Rehab Center LLC Registered Agent: Moshe Orlinsky	Legal Action: Class I Notice of Noncompliance In a letter from DHSS: On 05/13/2009, SLCR staff completed a revisit at the facility and determined that the Class I deficiency could be lowered to a Class II.
Description: The facility failed to monitor and document one of five sampled residents’ condition following an emergency room evaluation and failed to administer routine medications as ordered. The resident’s condition deteriorated and staff found the resident slumped over the toilet. Staff returned the resident to his/her room, did not assess him/her, and staff failed to follow the physician’s order to send the resident to the hospital. The resident expired (Resident #1). The facility also failed to monitor and document on one of six expanded sampled residents after the resident had an acute change in condition (Resident #2).
Facility: Life Care Center of St. Louis St. Louis, MO 100-Bed Skilled Nursing Facility Date of Notice: May 2009	Owner: HCRI Missouri Properties LLC Operator: C.M.C. Extended Care Center, Inc. Registered Agent: CT Corporation System	Legal Action: Uncorrected Class II Notice of Noncompliance
Description: The facility failed to follow physician’s orders for six of nine sampled residents and failed to follow acceptable standards of practice for the administration of medications. The facility failed to ensure staff provided two residents, who were unable to do their own activities of daily living (ADL’s), the necessary care and services to maintain good personal hygiene and prevent body odor. The facility failed to provide the appropriate treatment and services to minimize the potential for complications from tube feeding (TF) for four residents. The facility failed to implement a safe and effective system of medication administration, resulting in a 7.54% medication error rate. The facility failed to provide acceptable infection control practices and failed to provide a safe and sanitary environment to prevent the transmission of infection for one resident. The facility failed to ensure that nursing staff washed their hands after each direct resident contact and when indicated by professional practices during personal care for five residents.
Facility: Desmet Retirement Community Florissant, MO 90-Bed Residential Care Facility Date of Notice: May 2009	Owner: Desmet RHF Housing, Inc. Operator: Desmet RHF Housing, Inc. Registered Agent: National Registered Agents, Inc.	Legal Action: Uncorrected Class I Notice of Noncompliance In a letter from DHSS: On 04/29/2009, SLCR staff completed a revisit at the facility and determined that the Class I deficiency could be lowered to a Class II.
Description: The facility failed to meet the needs for two of two sampled residents. One resident, who experienced a fall and left side weakness, was sent to the hospital and diagnosed with a cerebrovascular accident. One resident’s laboratory results were not reported to the physician. The resident became weak, could not stand, had slurred speech, and was sent to the hospital. The resident was diagnosed with a urinary tract infection, possible septicemia, and dehydration.
Facility: Brook View Nursing Home, Inc. Maryland Heights, MO 201-Bed Skilled Nursing Facility Date of Notice: June 2009	Owner: Lierman Family Partnership LLP Operator: Brook View Nursing Home, Inc. Registered Agent: Mark Liermann	Legal Action: Uncorrected Class II Notice of Noncompliance
Description: An annual survey and abbreviated survey was completed on 03/31/2009. The facility was not in compliance with participation requirements. A revisit was completed on 05/21/2009. The facility failed to make correction to the following violations: Assess and analyze medical symptoms prior to using restraints, to determine the appropriateness and least restrictive interventions. Update five residents’ care plans to reflect the residents current needs; Ensure nursing staff adequately document the resident’s ongoing condition in the resident’s nurses’ notes, monitor consumption records to ensure facility staff were documenting meal consumption, failed to monitor nutritional deficits, and failed to ensure the resident received adequate liquids for one resident diagnosed with malnutrition; To complete an updated pain assessment and failed to develop interventions and approaches to address the resident’s pain; Ensure residents received the necessary care and services to promote healing and prevent new sores from developing; Ensure one resident’s indwelling urinary catheter drainage bag and tubing remained off the floor, which presented a risk for urinary tract infection, and failed to monitor and provide services to prevent the recurrence of a urinary tract infection; Ensure one resident who the facility identified at high risk for falls received adequate oversight and supervision to prevent accidents when staff placed the resident in a geri-rocker with tray and the resident fell out and pulled the television out of the cabinet; To implement a system to maintain proper temperatures for one of two medication refrigerators, used to store insulin and other medications that required refrigeration; facility staff failed to ensure they removed soiled gloves and washed hands as necessary during personal care for six residents.
Facility: Oasis Residential Care – West St. Louis, MO 20-Bed Residential Care Facility Date of Notice: June 2009	Owner: King, Nettie Operator: Oasis Residential Care, Inc. Registered Agent: Sherman Strong	Legal Action: Uncorrected Class II Notice of Noncompliance
Description: The facility failed to follow physician’s orders for one resident who did not receive intramuscular injections, blood pressure medication, and blood pressure checks. The facility also failed to follow physician’s orders for one resident who refused his/her treatment medications.
Facility: Mary, Queen and Mother Center Shrewsbury, MO 230-Bed Skilled Nursing Facility Date of Notice: June 2009	Owner: Mary, Queen and Mother Assn. Operator: Mary, Queen and Mother Registered Agent: Karen Ledbetter	Legal Action: Class I Notice of Noncompliance
Description: Based on interview and record review, the facility failed to provide timely and ongoing monitoring and assessment for one of three sampled residents (Resident #50). The resident’s condition deteriorated and staff failed to report findings to the resident’s physician in a timely manner, and failed to follow the resident’s directive and the physician’s order to provide Cardiopulmonary Resuscitation (CPR) when staff discovered the resident was without signs of life. The resident expired. The census was 203 residents.
Facility: Union Manor Residential Care Facility St. Louis, MO 52-Bed Residential Care Facility Date of Notice: July 2009	Owner: Alma Cook Operator: Same Registered Agent: N/A	Legal Action: Class I Notice of Noncompliance
Description: The facility failed to act in a manner to protect residents from physical abuse, which adversely affected the resident (Resident #2). Residents #5, #8, #3, #7, and #4 verified that the abuse occurred to Resident #2 in the facility. The facility failed to ensure one resident (Resident #2) who was unable to speak, disoriented to time and place, and agitated at times, was free from physical and verbal abuse by facility staff.
Facility: Whispering Oaks Wildwood, MO 70-Bed Residential Care Facility Date of Notice: July 2009	Owner: Cox Real Estate Corporation Operator: Whispering Oaks RCF Registered Agent: Naren Chaganti	Legal Action: Class I Notice of Noncompliance
Description: The facility failed to ensure room temperatures did not exceed eight-five degrees (85) Fahrenheit (F), and failed to ensure resident’s comfort needs were met by allowing a heat index of 99 degrees Fahrenheit.
Facility: Bellefontaine Gardens Nursing & Rehab. St. Louis, MO 96-Bed Skilled Nursing Facility Date of Notice: July 2009	Owner: Not Listed Operator: Bellefontaine Gardens Nursing & Rehab, Inc. Registered Agent: James Lincoln	Legal Action: Uncorrected Class II Notice of Noncompliance
Description: The facility failed to effectively assess, supervise, and intervene to prevent the elopement of one resident.
Facility: Northgate Park Nursing Home Florissant, MO 158-Bed Skilled Nursing Facility Date of Notice: July 2009	Owner: LaSalle Real Estate Assets, LLC Operator: FLO-GP Leasing Co., LLC Registered Agent: Mayer Klein	Legal Action: Class I Notice of Noncompliance
Description: The facility failed to provide oversight and supervision for one of three sampled residents who staff assessed as an elopement risk and who had a history of elopement. The resident left the facility without staff knowledge. Staff did not check for missing residents when a door alarm sounded per the facility’s policy and procedure.
Facility: Marymount Manor Eureka, MO 174-Bed Skilled Nursing Facility Date of Notice: July 2009	Owner: City of Eureka Operator: Marymount Manor, LLC Registered Agent: Greg Spence	Legal Action: Uncorrected Class II Notice of Noncompliance
Description: At the revisit on 07/20/09 the facility was found to have the following uncorrected violations. The facility census was 118 residents. The facility staff failed to properly assess/evaluate the use of a restraint, obtain appropriate physician orders, care plan its use, and obtain informed consent before utilizing a restraint for one resident. Facility staff failed to review and revise a plan of care for falls for one resident with a history of falls. The facility staff failed to evaluate and analyze hazards and risks for falls, implement interventions to reduce the risks, and monitor and modify the interventions when necessary for two residents. The facility staff failed to remove soiled gloves and properly wash hands as needed when incontinent care was provided for five residents.
Facility: Union Manor Residential Care Facility St. Louis, MO 52-Bed Residential Care Facility Date of Notice: July 2009	Owner: Alma Cook Operator: Same Registered Agent: N/A	Legal Action: Uncorrected Class I & II Notice of Noncompliance
Description: The facility failed to act in a manner to protect residents from physical abuse, which adversely affected the resident (Resident #2). Residents #5, #8, #3, #7, and #4 verified that the abuse occurred to Resident #2 in the facility. During the revisit on 7/16/09, the perpetrator of the abuse continued to work and had contact with residents after the allegation of abuse was made. The facility failed to ensure one resident (Resident #2) who was unable to speak, disoriented to time and place, and agitated at times, was free from physical and verbal abuse by facility staff. During the revisit on 7/16/09, the perpetrator of the abuse continued to work and had contact with residents after the allegation of abuse was made. The facility failed to maintain a separation between floors by ensuring one of one door providing separation, in building one, between the first floor and the basement, was closed. The facility failed to ensure two of two sampled residents and one expanded sampled resident were able to negotiate a path to safety. The facility failed to provide three substantial meals per day for two of seven days of the week, Saturdays and Sundays.
Facility: Allways Kare Residential Facility St. Louis, MO 20-Bed Residential Care Facility Date of Notice: July 2009	Owner: Allways Kare Residential Facility Operator: Same Registered Agent: Not Listed	Legal Action: Uncorrected Class II Notice of Noncompliance
Description: The facility failed to have two unobstructed exits remote from each other. The facility failed to have inspections and written certifications of the complete fire alarm system in accordance with NFPA 72, 1999.
Facility: North Valley Nursing & Rehab. Center St. Louis, MO 94-Bed Skilled Nursing Facility Date of Notice: August 2009	Owner: North Valley Real Property LLC Operator: Same Registered Agent: Kimberly Kusack	Legal Action: Class I Notice of Noncompliance
Description: The facility failed to provide protective oversight and/or follow the facility’s policies on suicidal ideation, resident to resident altercations, daily room checks, and searches to prevent harm for six of nine sampled residents and provide a safe environment for other residents. The facility failed to adequately monitor one of nine sampled residents to prevent an elopement.
Facility: Tesson Heights St. Louis, MO 72-Bed Residential Care Facility Date of Notice: September 2009	Owner: HCP Tesson LLC Operator: CSL Leaseco, Inc. Registered Agent:  C T Corporation System	Legal Action: Uncorrected Class II Notice of Noncompliance
Description: The facility failed to ensure one of five sampled residents was able to negotiate a path to safety.
Facility: Sabbath Manor St. Louis, MO 64-Bed Residential Care Facility Date of Notice: September 2009	Owner: Sadaf, LLC Operator: Frasat, LLC Registered Agent: Bilkiss Cahudhry	Legal Action: Uncorrected Class II Notice of Noncompliance
Description: At the revisit on 09/03/2009, the facility still failed to ensure one of two required exits on the second floor was free of obstructions. During the onsite inspection, the door of the required exit in one resident room was obstructed by a resident bed and a bag of clothes.
Facility: Whispering Oaks Wildwood, MO 70-Bed Residential Care Facility Date of Notice: September 2009	Owner:  Cox Real Estate Corp. Operator: Whispering Oaks RCF Management Company, Inc. Registered Agent: Naren Chaganti	Legal Action: Class I Notice of Noncompliance
Description: The facility failed to provide protective oversight for a resident who climbed up onto the facility’s roof, while it was misting rain, to repair the facility’s guttering. The resident fell from the wet ladder approximately 15 feet to the flat roof below and sustained a deep laceration requiring 11 stitches. In addition, the facility failed to provide oversight for two sampled residents who work at the facility because there are no activities.
Facility: Avalon Garden St. Louis, MO 77-Bed Skilled Nursing Facility Date of Notice: October 2009	Owner: BRNCIC Inc. Operator: JPAM Management & Consulting, Inc. Registered Agent: John Brencick	Legal Action: Uncorrected Class II Notice of Noncompliance
Description: The facility failed to provide care that met professional standards of quality for four of nine sampled residents. The facility failed to apply pressure relieving boots 24 hours a day and follow a physician’s order to obtain a timely podiatry consult for one resident with a recurring pressure ulcer on the heel, failed to document dietary consumption/nutritional supplements based on per meal intake for one resident with a weight loss, failed to maintain documentation as ordered for blood oxygen level testing per shift for one resident who received routine oxygen, and failed to dress one dependent resident in compression stockings as ordered.
Facility: Keaton Center Arnold, MO 24-Bed Assisted Living Facility Date of Notice: October 2009	Owner: Community Treatment Inc. Operator: Same Registered Agent: Not Listed	Legal Action: Class I Notice of Noncompliance
Description: The facility failed to correct a fault with the complete fire alarm system.
Facility: Sabbath Manor St. Louis, MO 64-Bed Residential Care Facility Date of Notice: October 2009	Owner: Sadaf LLC Operator: Frasat, LLC Registered Agent: Bilkiss Cahudhry	Legal Action: Uncorrected Class II Notice of Noncompliance
Description: At the revisit on 09/23/2009, the facility failed to correct deficiencies related to the installation of manual pull stations; installation of interconnected smoke detectors; installation of smoke separation barriers in resident use areas; providing emergency lighting of sufficient intensity and maintaining electrical wiring in good repair.
Facility: Wilbar Boarding Home St. Louis, MO 49-Bed Residential Care Facility Date of Notice: October 2009	Owner: William Baker Revocable Trust Operator: Wilbar Boarding Home, Inc. Registered Agent: William Baker	Legal Action: Uncorrected Class II Notice of Noncompliance
Description: At the revisit, the facility failed to: Use the personal funds of residents, exclusively for the residents by keeping the resident’s stimulus check as payment for room and board; Purchase a surety bond to ensure protection of resident funds.
Facility: Beauvais Manor Healthcare & Rehab Center St. Louis, MO 184-Bed Skilled Nursing Facility Date of Notice: October 2009	Owner: Beauvais Manor Property, LLC Operator: Beauvais Manor Healthcare & Rehab Center, LLC Registered Agent: Robin Suydam	Legal Action: Class I Notice of Noncompliance
Description: The facility failed to provide adequate supervision and an environment to mitigate accidents. Staff failed to prevent one confused resident from leaving the facility, unnoticed and unattended. The resident left the facility at 12:30 p.m. and was returned by the police at 4:15 p.m. Staff were unaware the resident left the facility until they were notified by a nearby local business.
Facility: Autumn View Gardens Ellisville, MO 150-Bed Assisted Living Facility Date of Notice: October 2009	Owner: Bethesda Foundation Operator: Same Registered Agent: C T Corporation System	Legal Action: Uncorrected Class II Notice of Noncompliance
Description: The facility failed to complete an evacuation plan for two of three sampled residents and for two expanded sampled residents. The facility failed to ensure residents were able to evacuate the facility with minimal assistance for two of three sampled residents. The facility failed to ensure community based assessments were completed within five calendar days of admission for one of three sampled residents admitted to the facility. The facility failed to update residents individualized service plans (ISP) for identified care areas and failed to review the ISP with the resident or the resident’s legal representative, for two of six sampled residents and two expanded sampled residents. The facility failed to complete resident’s individualized service plan (ISP) when a significant change in the resident’s condition occurred and failed to review the changes with the resident or the resident’s legal representative, for two expanded sampled residents. The facility failed to obtain physician’s orders for two expanded sampled residents to self administer medications. The facility failed to ensure medications were administered in an appropriate and timely manner, according to acceptable nursing techniques, for four expanded sampled residents.
Facility: The Villas De Soto, MO 51-Bed Skilled Nursing Facility Date of Notice: November 2009	Owner: Lierman Family Co. IV LLC Operator: Heather Nixon Registered Agent: NA	Legal Action: Class I Notice of Noncompliance
Description: The facility failed to ensure hot water temperatures in resident accessible areas did not exceed 120 degrees Fahrenheit (F). This placed residents at risk of serious burn injury. This condition affected a total of 24 residents who were ambulatory with cognitive impairment, at risk for wandering, had diabetes, peripheral vascular disease, or neuropathies (decreased circulation).
Facility: U-City Forest Manor St. Louis, MO 120-Bed Skilled Nursing Facility Date of Notice: November 2009	Owner: U-Forest Place, LLC Operator: U-City Forest Manor, LLC Registered Agent: Sharo Shirshekan	Legal Action: Class I Notice of Noncompliance
Description: The facility failed to provide protective oversight by assuring a confused resident with a history of exit seeking behavior, did not leave the facility without supervision. The resident left the facility without staff knowledge and was returned to the facility by local police at approximately 5:00 a.m. The resident was not appropriately dressed or wearing a facility identification wrist band.
Facility: Garden View Care Center Dougherty Ferry Valley Park, MO 120-Bed Skilled Nursing Facility Date of Notice: December 2009	Owner: GVCC Partnership Operator: Garden View Care Center of St. Louis, Inc. Registered Agent: Scwhra, Inc.	Legal Action: Uncorrected Class II Notice of Noncompliance
Description: The facility failed to thoroughly investigate the circumstances of residents’ falls in a manner which would allow them to implement interventions to reduce falls or prevent accidental injury as a result of the falls and failed to investigate the circumstances which surrounded a resident’s severely bruised hand to prevent another injury of its kind. The facility failed to assess and notify the physician in a timely manner of the development of a pressure ulcer.
Facility: The Westchester House Chesterfield, MO 159-Bed Skilled Nursing Facility Date of Notice: December 2009	Owner: Chesterfield Medical Inventors, LLC Operator: Consolidated Resources Health Care Fund I Registered Agent: The Corporation Company	Legal Action: Uncorrected Class II Notice of Noncompliance
Description: The facility failed to ensure physicians’ orders were followed and documentation of intake and output was completed for three sampled residents who have tube feeding orders. The facility failed to ensure staff followed and administered the Registered Dietician’s recommendations for two sampled residents who received tube feedings and had pressure ulcers.
Facility: Sunrise on Clayton Richmond Heights, MO 90-Bed Intermediate Care Facility Date of Notice: December 2009	Owner: HCP Sun2 Richmond Heights, Missouri LLC Operator: Sunrise Senior Living Management, Inc. Registered Agent: C T Corporation	Legal Action: Class I Notice of Noncompliance
Description: The facility failed to provide protective oversight for one of two sampled residents with dementia and a history of elopement. The resident left the facility, undetected by staff, during the night. The resident was found crossing a well traveled road by a passerby, who called the police.