PRINTED: 04/26/2011

DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED

CENTERS FOR MEDICARE & MEDICAID SERVICES OMS NO 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING

B. WING _
C
260141 03/30/2011
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
ONE HOSPITAL DRIVE. ROOM CE121. DC031.00
UNIVERSITY OF MISSOURI HEALTH CARE
COLUMBIA. MO 65201
(X4) 10 SUMMARY STATEMENT OF DEFICIENCIES 10 I PROVIDER'S PLAN OF CORRECTION (X5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX I
(EACH CORRECTIVE ACTION SHOULD BE COMPLETION
CROSS-REFERENCED TO THE APPROPRIATE DATE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG
DEFICIENCy)

A 000 INITIAL COMMENTS AOOO

As instructed by the Centers of Medicare and

Medicaid (CMS), the following complaints were
investigated in conjunction with the revisit on the
full Medicare survey conducted on 01125/11.

M000068678, M000069196, M000068833. All

complaints were found to be unsubstantiated with
no related deficiencies.

I I
TITLE (X6) DATE
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that
other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days
following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14
days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued
program participation.

FORM CMS-2567(02-99) Previous Versions Obsolete Event 10:W24F11 Facility 10: 260141 If continuation sheet Page 1 of 1
 PRINTED: 04/2612011
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMS NO 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING
B. WING _
R
260141 03/30/2011
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
ONE HOSPITAL DRIVE, ROOM CE121, DC031 ,00
UNIVERSITY OF MISSOURI HEALTH CARE
COLUMBIA, MO 65201
(X4) 10 SUMMARY STATEMENT OF DEFICIENCIES 10 PROVIDER'S PLAN OF CORRECTION (X5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE
TAG TAG
DEFICIENCy)

{A OOO} INITIAL COMMENTS {AOOO}

As directed by the Centers of Medicare and

Medicaid (CMS), an unnanounced revisit was
conducted at this facility 'from 03/28/11 - 03/30/11.
All citations were corrected.

TITLE (X6) DATE

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that
other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days
following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14
days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued
program participation.

FORM CMS-2567(02-99) Previous Versions Obsolete Event 10:YH7812 Facility ID: 260141 If continuation sheet Page 1 of 1