Columbia Post Acute, Columbia, MO: The facility staff failed to address an acute medical change in condition for one resident when the resident had a low blood sugar and full cardiac arrest. The facility failed to orient the agency nurse to the emergency supplies. Additionally, the facility staff failed to initiate CPR for the full code resident when the resident declined and was without pulse or respirations.

Converse Home, Florissant, MO: The facility failed to provide protective oversight to residents who expressed thoughts of self-harm when staff did not follow-up with the resident’s physician to determine the appropriate course of action and did not implement an immediate plan to ensure safety for two residents.

Shady Oaks Retirement Home, Poplar Bluff, MO: The facility failed to ensure three residents were free from physical and emotional abuse. The facility owner open-handedly slapped one resident across the face, punched the resident’s groin area, and jerked the resident’s arm when the resident soiled his/her clothes. The facility owner open-handedly slapped a second resident across the face, jerked on the resident’s arm and yelled at the resident for soiling his/her clothes. The owner also smacked a third resident’s hands.

St. Joe Manor, Bonne Terre, MO: A complaint investigation was conducted. The facility failed to ensure that two residents who resided on the secured unit remained free from abuse. Staff identified Resident #1 going into another resident’s room. The second resident became angry and struck out when someone came into his/her room. The facility failed to implement interventions to prevent abuse and failed to provide sufficient protection for Resident #1 by not immediately intervening after an altercation. Resident #1 suffered head trauma and subsequently death as a result of the altercation. The facility failed to thoroughly investigate an incident of resident to resident abuse and failed to implement interventions to prevent further abuse from occurring for one resident, when one resident initially struck another resident in the head. The facility also failed to take appropriate action to ensure the safety of the five remaining residents who continued to reside on the secured unit.

Sunnyview Nursing Home and Apartments, Trenton, MO: A complaint investigation was conducted. The facility failed to ensure one resident’s environment was free of accident hazards and keep the resident free from injury when facility staff failed to secure the resident in the facility van during a transport. The van driver slammed on the brakes and the resident, who was not secured, fell forward, hitting his/her head, resulting in multiple skin tears on both arms and legs, a fractured nose and fractured cervical spine, resulting in hospitalization.