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.