Missouri Department of Health and Senior ServicesP.O. Box 570, Jefferson City, MO 65102-0570 Phone: 573-526-8523 FAX: 573-526-8797RELAY MISSOURI for Hearing and Speech Impaired 1-800-735-2966 VOICE 1-800-735-2466Margaret T. DonnellyDirector

Jeremiah W. (Jay) NixonGovernor

MEMORANDUM FOR MATT YOUNGER, SECTION ADMINISTRATORSECTION FOR LONG-TERM CARE REGULATIO~

FROM: Carla Jennings, Program Manager %'Section for Long-Term Care Regulation

Jefferson Health Care (A Special Focus Facility-SFF)615 SW Oldham ParkwayLee's Summit, MO 64081

Administrator/Manager -- Michelle LeiphamOperator -- Jefferson Health Care, Inc.Registered Agent -- Clifton Shirrell

Class I Notice of Noncompliance:The facility staff failed to provide adequate protective oversight and supervision andnursing care in accordance with the resident's condition for one sampled resident(Resident #3) who is diagnosed with dementia and had a history of falls who had anunwitnessed fall on 6/30/12 resulting in a larger than golf ball size hematoma (alocalized collection of blood outside the blood vessels) on his/her head; an unwitnessedfall on 7/21/12 resulting in a subdural hematoma (a collection of blood on the surface ofthe brain usually the result of a serious head injury); and an unwitnessed fall on 8/8/12resulting in an acute-on-chronic subdural hematoma (additional bleeding at the site ofthe previous subdural hematoma) after being left unsupervised by the facility staff. Thefacility staff failed to comprehensively assess and develop an individualizedinterdisciplinary care plan with interventions to instruct staff on how to keep the residentsafe from further injury from falls.

State Senator -- Will KrausState Representative -- Jeff Grisamore

cc: Teresa Generous, Matt Younger, Larry Smith, CRU, Lieutenant Governor's Office,Central Files, Health Education Unit, SLCR Region 3, DSDS Region 4, Ombudsman,BNHA, Family Support Division, DMH, VA Medical Center, LTC Associations, S&C,DHSS Office Of General Counsel

www.health.mo.govHealthy Missourians for life.

The Missouri Department of Health and Senior Services will be the leader in promoting, protecting and partnering for HealthAN EQUAL OPPORTUNITY I AFFIRMATIVE ACTION EMPLOYER: Services provided on a nondiscriminatory basis.

Missouri Department of Health and Senior ServicesP.O. Box 570, Jefferson City, MO 65102-0570 Phone: 573-526-8523 FAX: 573-526-8797RELAY MISSOURI for Hearing and Speech Impaired 1-800-735-2966 VOICE 1-800-735-2466

Margaret T. DonnellyDirector

Jeremiah W. (Jay) NixonGovernor

Clifton Shirrell, Registered AgentJefferson Health Care, Inc.731 North Main StreetSikeston, MO 63801

Michelle Leipham, AdministratorJefferson Health Care615 SW Oldham ParkwayLee's Summit, MO 64081

The Section for Long-Term Care Regulation (SLCR) is required by Section198.029, RSMo, to immediately issue a Notice of Noncompliance when it finds aviolation or violations in a facility, which present either an imminent danger to thehealth, safety or welfare of any resident or a substantial probability that death orserious harm would result. The SLCR issued such a Notice of Noncompliance toJefferson Health Care based on the Class I violations found during therecertification survey and abbreviated survey (complaint investigation) completed08/28/2012. The SLCR informed you of the Class I violations, in writing, and inan exit interview on 08/28/2012. The Class I violations and additional Class IIand Class III violations cited during the recertification survey and abbreviatedsurvey are listed in the enclosed Statement of Deficiencies.

The SLCR has reviewed the available information and determined that althoughthe conditions in your facility constituted Class I at the time of the recertificationsurvey and abbreviated survey, the deficiency was found to be lowered to aClass II prior to exit. Even though the Class I violation was lowered to a Class IIprior to exit, the facility may still face liability for a Class I Civil Monetary Penaltypursuant to 198.067 RSMo.

You must submit an acceptable plan of correction for the Class II and Class IIIviolations within ten (10) working days of your receipt of the Statement ofDeficiencies to the SLCR Region 3,1410 Genessee, Ste. 130, Kansas City, MO64102. Your Plan of Correction MUST NOT INCLUDE THE NAMES OFRESIDENTS. In addition, your plan of correction should not include otherresident specific information such as.medical records.

Representatives of the SLCR will monitor the facility until further notice and willconduct a revisit in the near future to determine whether you are takingappropriate steps to address the violations. If at the time of the revisit the

www.heulth.mo.gol.Healtby Missourians for life.

The Missouri Department of Health and Senior Services will be the leader in promoting, protecting and partnering for HealthAN EQUAL OPPORTUNITY / AFFlRMA TIVE ACTION EMPLOYER: Services provided on a nondiscriminatory basis.

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198.067, RSMo, or may take any action authorized by law. In accordance withSection 198.067, RSMo, the SLCR may also refer this matter to the circuit courtfor consideration for a monetary penalty.

In accordance with Section 198.545, RSMo, you have one (1) opportunity toquestion cited deficiencies through an informal dispute resolution process. To begiven such an opportunity, you -are required to send your written request(separate from the plan of correction), along with the specific deficiencies beingdisputed, and an explanation of why you are disputing those deficiencies to:

Lisa StewardPrimaris200 N. Keene StreetColumbia, MO 65201Tel #: 573-817-8300Isteward@primaris.org

Please include a copy of the statement of deficiencies being disputed with yourcorrespondence to Primaris.

Michele McElroy-OtisRegional ManagerSLCR Region 31410 Genessee, Ste. 130Kansas City, MO 64102

This request must be sent during the same ten (10) calendar days you have forsubmitting a plan of correction for the cited deficiencies. The informal disputeresolution may be conducted by telephone, in writing or in a face-to-facemeeting. An incomplete informal dispute resolution process will not delay theeffective date of any enforcement action.

As required by Section 198.029, RSMo, the SLCR will make public the fact that aNotice of Noncompliance was issued and will send copies of the notice toappropriate government agencies. Please note that based on the fact that thedeficiency was found to be lowered to a Class II prior to exit, you will receive nofurther notification regarding the lowering of the classification of the deficiency.

If you have questions, please contact Carla Jennings, Program Manager, atTelephone #: 573/526-4976.

o

Sincerely,

Matt You er, AdministratorSection for Long-Term Care

MY/cj/csEnclosurecc: Lieutenant Governor's Office

Division of Family ServicesllMDepartment of Mental HealthCentral FilesArea Hospitals (Jackson County)LTC AssociationsSLCR Region 3