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 REGULATION

Kathryn Wolfe, Interim Program Manager«WSection for Long- Term Care Regulation

Stoney Ridge Village25023 Bothwell Park Rd.Sedalia, MO 65301

Manager - Elizabeth ButterbaughOperator-A H G - Stoney Ridge, LLC

Class I Notice of Noncompliance: The facility failed to ensure that no section of thebuilding shall present a fire hazard when a resident room contained two 29 liter portableliquid oxygen systems. The facility failed to ensure no combustible material was storedon top of the liquid oxygen systems.

A licensure inspection was completed on 02/21/2011. The facility was not in compliancewith licensure requirements. Revisits were completed on 06/13/2011, 07/19/2011,09/27/2011,02/07/2012, and 05/14/2012. The facility failed to take the followingcorrective action.

-The facility failed to maintain wall and ceiling surfaces free of highly combustiblematerials.

-The facility failed to maintain drapes or curtains certified or treated to be flame-resistantas defined in NFPA 101, 2000 edition.

-The facility failed to use only metal, UL, or FM fire resistant waste baskets for trashdisposal.

-The facility failed to maintain electrical wiring in accordance with the National ElectricalCode, 1999 edition.

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.

State Senator - Chuck PurgasonState Representative - Diane Franklin

cc: Teresa Generous, Matt Younger, Sallianne Thompson, Marsha Stanton, CRU,Lieutenant Governor's Office, Central Files, Health Education Unit, SLCR Region 6,Ombudsman, DSDS Senior Services Region 4, OGC, DMH, JosephBindbeutellAttorney General's Office, VA Medical Center, LTC Associations, S&C,DHSS Office Of General Counsel, Ron Thompson, Deputy Chief of Inspectors

Missouri Department of Health and Senior ServicesP.O. Box 570, Jefferson City, MO 65102-0570 Phone: 573-751-6400 FAX: 573-751-6010RELAY MISSOURI for Hearing and Speech Impaired 1-800-735-2966 VOICE 1-800-735-2466

Margaret T. DonnellyDirector

Jeremiah W. (Jay) NixonGovernor

National Registered Agents, Inc., Registered Agent ups- 1Z A33 9F3 03 95559358AHG - Stoney Ridge, LLC300 B East High StreetJefferson City, MO 65101

Elizabeth Butterbaugh, Manager UPS- 1Z A33 9F3 03 9944 2145Stoney Ridge Village25023 Bothwell Park Rd.Sedalia, MO 65301

The Section for Long-Term Care Regulation (SLCR) is required by Section 198.029, RSMo, toimmediately issue a Notice of Noncompliance when it finds a violation or violations in a facilitywhich present either an imminent danger to the health, safety or welfare of any resident or asubstantial probability that death or serious harm would result. The SLCR issued such aNotice of Noncompliance to Stoney Ridge Village based on the Class I violation found during arevisit completed 05/14/2012. The SLCR informed you of the Class I violation, in writing, andin an exit interview on 05/14/2012. The Class I violation and additional uncorrected Class IIand uncorrected Class III violations cited during the revisit are listed in the enclosed Statementof Deficiencies.

The SLCR has reviewed the available information and determined that although the conditionsin your facility constituted Class I at the time of the 05/14/2012 revisit, the deficiency was foundto be lowered to a Class II prior to exit. Even though the Class I violation was lowered to aClass II prior 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 uncorrected Class II and uncorrectedClass III violations within ten (10) working days of your receipt of the Statement of Deficienciesto The Division of Fire Safety (DFS), Ron Thompson, 205 Jefferson Street 13th FJoor, P. O.844, Jefferson City, MO 65102. Your Plan of Correction MUST NOT INCLUDE THE NAMESOF RESIDENTS. In addition, your plan of correction should not include other resident specificinformation such as medical records.

As required by Section 198.029, RSMo, the SLCR will make public the fact that a Notice ofNoncompliance was issued and will send copies of the notice to appropriate government

Healtby Missourians for life.The Missouri Department of Health and Senior Services will be the leader in promoting, protecting and partnering for health.

agencies. Please note that based on the fact that the deficiency was found to be lowered to aClass II prior to exit, you will receive no further notification regarding the lowering of theclassification of the deficiency.

The SLCR has reviewed the facility's record, the cited violations and the· circumstances andhas determined to deny your application for a license to operate Stoney Ridge Village, a 160bed Residential Care Facility.

This decision is based on the following grounds which, individually, are found to be sufficientfor denial of the application for a license:

I:&l The operator failed to ensure substantial compliance with the provisions of sections198.003 to 198.096, RSMo and the standards established there under. See Section198.022.1 (2), RSMo.I:&l The operator has failed to provide a complete application, including all requiredattachments. See Section 198.022.1 (3), RSMo.I:&lThe operator has failed to provide a complete application, including all requiredattachments, demonstrating financial capacity to operate the facility. See Section198.022.1 (3), RSMo.I:&lThe operator failed to ensure all fees due to the state have been paid.

The facts, upon which the decision is based, are as follows:• The fadlity is in violation of the provisions of sections 198.003 to 198.096, RSMo and the

standards established there under as evidenced by the Class I and uncorrected Class IIand uncorrected Class III violations listed in the enclosed Statement of Deficiencies.

• On 02/21/2011, the Missouri Division of Fire Safety (DFS) conducted an annual licensureinspection at Stoney Ridge Village and the facility was found to be out of compliance with19 CSR 30-86.032(13), which states, "In facilities that are constructed or have plansapproved after July 1, 2005, electrical wiring shall be installed and maintained inaccordance with the requirements of the National Electrical Code, 1999 edition, NationalFire Protection Association, Inc., incorporated by reference, in this rule and available bymail at One Batterymarch Park, Quincy, MA 02269, and local codes. This rule does notincorporate any subsequent amendments or additions to the materials incorporated byreference. Facilities built between September 28, 1979 and July 1, 2005 shall bemaintained in accordance with the requirements of the National Electrical Code, which wasin effect at the time of the original plan approval and local codes. This rule does notincorporate any subsequent amendments or additions. In facilities built prior to September28, 1979, electrical wiring shall be maintained in good repair and shall not present a safetyhazard. All facilities shall have wiring inspected every two (2) years by a qualifiedelectrician." This deficiency was cited as a Class II level deficiency.

• On 06/13/2011, 07/19/2011, 09/27/2011 and 02/07/2012, DFS conducted revisits at theFacility and made the determination that the Operator had not corrected the deficiencycited at 19 CSR 30-86.032(13). Notices of Noncompliance were issued to the Facility on06/27/2011,08/10/2011,10/12/2011 and 02/23/2012. On 05/14/2012, DFS conducted arevisit and found that the Operator had not corrected 19 CSR 30-86.032(13) and found aClass I violation at 19 CSR 30-86.022(2)(0).

• The Operator failed to provide all required information related to the principals in the operationof the facility, including social security numbers.

• The Operator failed to submit M0580-2622 (Assurance of Compliance) attesting that itcomplies with the provisions of Title VI of the Civil Rights Act 1964, as amended; Section 504of the Rehabilitation Act of 1973; Title IX of the Education Amendment of 1972; the AgeDiscrimination Act of 1975; the Omnibus Budget and Reconciliation Act of 1982; theAmericans with Disabilities Act of 1990; and the Keyes Amendment to the Social Security Act.

• The Operator failed to submit the required $600 licensure fee.• The Operator failed to submit written notification of a stockholder change in the Operating

entity. According to statements made by Norman Wilcox on November 18th, 2011, the facilityunderwent a change in stockholder in March, 2011, however, the change was not submitted toSLCR, as required. Mr. Wilcox was advised to submit updated affiliate documentation to theSection on November 18, 2012 and on January 30, 2012. The Operator failed to submit theinformation prior to submission of the May 4, 2012 application. The application submitted onMay 4, 2012 also did not include information related to the stockholder change within AHG-Stoney Ridge, LLC.

• The operator failed to submit changes made to the Managers and Members of the operatingentity AHG Stoney Ridge, LLC, including the name, address, and title of each LLC manager,and the name, address, title and percentage of ownership of each LLC member.

• The operator failed to demonstrate the financial capacity to operate a long term care facility.SLCR requested information relating to the financial capacity of AHG Stoney Ridge, LLC onAugust 16, August 24, August 25, August 30, November 18, 2011 and/or February 8, 2012.

• The operator failed to submit documentation that debts owed to the Department of Revenuehave been paid (approximately $24,995.89), releasing the need for the garnishment againstthe facility operating account.

• The operator failed to submit documentation of debt owed to the Internal Revenue Service(IRS).

• The Operator failed to provide documentation regarding payment made on property taxesowed to the county of Pettis to ensure the facility is not in danger of being sold on thecourthouse steps again this coming year and/or provide the Department with a plan on how theOperator will ensure that payment is made in a timely manner to Pettis County.

• The Operator failed to provide documentation related to financial capacity, includinginformation to explain large checks written out from the facility operating account in July 2011to other entities, which are other business interests of Mr. Wilcox's (both in MO and in KS),including Superior Senior Living, BTH Family Partnership, Peak Senior Living, Superior Dining,and AHG-Superior. None of these entities have been disclosed as being part of the operatingentity of AHG-Stoney Ridge, LLC or Advantage Health Group, Inc.

On 04/30/2012, SLCR issued Temporary Operating Permit (TOP) # 040185 to your facility withan expiration date of 06/05/2012. Enclosed you will find TOP #040250. This TOP will beeffective 06/06/2012 and will null and void on 07/09/2012.

If you continue to care for more than two (2) residents after the TOP becomes null and void,you will be operating without a state license at that time, in violation of Sections 198.015.1,

RSMo Supp. 2003 and 198.061.1, RSMo, and the SLCR may request your criminalprosecution or may take any other action authorized by law.

Section 198.039.1, RSMo, provides that you may appeal the SLCR'sdenial of your license tothe Administrative Hearing Commission. Your petition for appeal must be filed within fifteen(15) days after the date of the mailing of this letter. The Commission's address is TrumanState Office Building, 301 West High Street, P.O. Box 1557, Jefferson City, MO 65102.

If you have questions, please contact Kathryn Wolfe, Interim Program Manager, at 573/526-3247.

~~~

MattYounger,SectionAdminis~rSection for Long-Term Care Regulation

cc: Lieutenant Governor's OfficeDivision of Family ServicesllMDepartment of Mental HealthCentral FilesArea Hospitals PettisLTC AssociationsDivision of Fire Safety-Ron Thompson