The Springfield violation involved a fatal overdose of oxycontin administered to a resident at The Neighborhoods at Quail Creek on Jan. 14. According to the website:
Based on observation, interview and record review, the facility failed to provide appropriate care to one resident (Resident #1) after a certified medication technician gave the resident a lethal dose of a narcotic pain medication on 1/14/07 that was ordered for another resident. Facility staff failed to carry out and document physician's orders for vital signs, notifying physician of decreased respirations and lethargy, and holding Resident #1's routine medications. Based on observation, interview and record review, facility staff failed to ensure staff identified and administered medication to the proper resident (Resident #1) that resulted in significant medication errors. On 1/14/07, a certified medication technician administered eight medications (including the narcotic pain medication Oxycontin) to Resident #1 that was ordered for another resident. On 1/17/07 the resident died. The coroner said Resident #1 received a lethal dose of Oxycontin on 1/14/07. The facility census was 65 residents.
The Neosho incident occurred at Springhill Assisted Living by Americare and was described this way on the website:
Based on observation, interview, and record review, the facility failed to ensure hot water temperatures were within the required range in resident rooms and resident-use common areas. Seventeen (17) of eighteen (18) residents were ambulatory and could access the hot water independent of staff. The facility census was 18.