| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/31/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265530 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER JEFFERSON CITY NURSING AND REHABILITATION CTR, LLC | STREET ADDRESS, CITY, STATE, ZIP 1221 SOUTHGATE LANE | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0550 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | Honor the resident’s right to a dignified existence, self-determination, communication, and to exercise his or her rights. Based on observation, interview, and record review, facility staff failed to maintain |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/31/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265530 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER JEFFERSON CITY NURSING AND REHABILITATION CTR, LLC | STREET ADDRESS, CITY, STATE, ZIP 1221 SOUTHGATE LANE | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0550 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 1) near a small corner table with a table top size of 16×15 and a height of 23 1/2 in an open area adjoining the main dining area. Further observation showed staff did not include the resident in an activity initiated by staff with residents who sat at the tables in the adjoining dining room. Additional observation showed the resident continued to twist the chair tag with his/her hands. Observation on 08/16/18 at 12:03 P.M., showed the resident in his/her broda chair alone at a small corner table with a table top size of 16×15 and a height of 23 1/2 in an open area adjoining the main dining area. Further observation showed staff did not provide the resident with silverware and he/she ate the meal with his/her hands. Observation on 08/17/18 at 1:19 P.M., showed the resident in his/her broda chair alone at a small corner table with a table top size of 16×15 and a height of 23 1/2 in an open area adjoining the main dining area. Further observation showed staff did not provide the resident with silverware and he/she ate the meal with his/her hands. Additional observation showed the table pushed outward from the corner and a cup of milk spilled in between the table and the nurse’s desk. Staff did not replace the resident’s milk and did not offer any assistance to the resident with his/her meal. During an interview on 08/16/18 at 12:06 P.M., Certified Nursing Aide (CNA) B said the resident sits in the corner using the little table because it is in his/her care plan. He/She said the resident used to sit at a regular table in the past but would grab his/her plate and roll into the middle of the room to eat. He/She said the resident would get upset with other residents and pull the tablecloths off. During an interview on 08/16/18 at 5:01 P.M., the MDS Coordinator said he/she completes the residents’ care plans, but the department heads assist her as needed with their section of the care plan. He/She said if a care plan says to allow a resident to eat alone, that intervention should be implemented in a way to prevent isolation. He/She said staff should ask if they have questions on how care plan interventions should be implemented. During an interview on 08/16/18 5:13 P.M., the Registered Dietitian (RD) said if staff have implemented a care plan intervention for the resident to sit alone staff should sit the resident at a table where they are comfortable and still able to socialize. The RD said staff should not place residents in a corner to eat. He/She said the place the resident sits to eat is not a corner, just a corner area near the nurse’s desk right outside the dining room. He/She said staff place the resident there to keep an eye on him/her. During an interview on 08/17/18 at 1:15 P.M., Licensed Practical Nurse (LPN) A said the resident gets agitated and can be violent toward other residents so they place him/her at a small table and he/she does well. He/She said staff could place the resident at a better table and he/she is unsure if they have tried anything else in the past. The LPN said he/she does not like the resident being secluded like he/she is currently. During an interview on 08/17/18 at 1:39 P.M., the Maintenance Assistant referred to the small corner table in the room adjoining the dining room as wobbly and said it slides too easily on the floor to use as a dining table. | |
| F 0641 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | Ensure each resident receives an accurate assessment. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/31/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265530 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER JEFFERSON CITY NURSING AND REHABILITATION CTR, LLC | STREET ADDRESS, CITY, STATE, ZIP 1221 SOUTHGATE LANE | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0641 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 2) accurate Minimum Data Set (MDS), assessment ( a federally mandated assessment tool) when they did not accurately code falls for one resident (Resident’s #30), weight loss and oxygen use for one resident (Resident’s #37), and antipsychotic medications for one resident (Resident #67). The facility census was 75. 1. Review of the Resident Assessment Instrument (RAI) manual, dated 10/1/17, showed: to complete an accurate assessment requires collecting information from multiple sources, some of which are mandated by regulations. Those sources must include the resident and direct care staff on all shifts, and should also include the resident’s medical record, physician, and family, guardian, or significant other as appropriate or acceptable. It is important to note here that information obtained should cover the same observation period as specified by the MDS items on the assessment, and should be validated for accuracy (what the resident’s actual status was during that observation period) by the interdisciplinary team (IDT) completing the assessment. 2. Review of Resident’s #30’s nurses notes, dated 5/21/18, showed staff documented on 5/19/18 the resident propelled himself/herself down the hallway and slid forward which resulted in the resident falling forward out of his/her wheelchair and landing on the floor. Facility staff documented the resident had a four inch raised lump above his/her left eye and a bruise at the left zygomatic arch (cheek), with two skin tears noted, one on each knee. Review of the resident’s MDS, dated [DATE], showed staff assessed the resident as follows: -Moderate cognitive impairment; -Required extensive assistance of one staff for bed mobility, transfers, dressing, toileting, and personal hygiene; -Did not have any falls. Review showed staff did not accurately code the resident’s fall on the MDS. During an interview on 8/21/18 at 9:15 A.M., the Director of Nursing (DON) said if the resident had a fall it should be coded on the MDS. 3. Review of Resident #37’s quarterly MDS, dated [DATE], showed staff assessed the resident as follows: -Cognitively intact; -Supervision and set up for bed mobility, transfers, and eating; -Required limited assistance of one or more staff for dressing, toileting, and hygiene; -Did not use oxygen; Review of the resident’s physician’s orders [REDACTED]. Observation on 08/13/18 at 2:17 P.M., showed the resident sat on his/her bed with a nasal cannula in place to deliver oxygen, and the oxygen concentrator set to deliver four liters of oxygen. Staff did not accurately code the resident’s MDS assessment to reflect oxygen use. 4. Review of Resident #67’s Admission MDS, dated [DATE], showed staff assessed the resident as follows: -Rarely/Never understood; -Did not display behaviors; -Did not have a [DIAGNOSES REDACTED]. -Did not receive antipsychotic medications; Review of the resident’s POS, dated 07/11/18, showed staff are directed to administer 50mg of [MEDICATION NAME] (antipsychotic) to the resident by mouth each night at bedtime. Staff did not accurately code the resident’s MDS assessment to show use of antipsychotic medication. 5. During an interview on 08/21/18 at 9:12 A.M., the MDS Coordinator said he/she completes |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/31/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265530 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER JEFFERSON CITY NURSING AND REHABILITATION CTR, LLC | STREET ADDRESS, CITY, STATE, ZIP 1221 SOUTHGATE LANE | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0641 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 3) the MDS by RAI guidelines and they try to meet required timeframe. He/She expects the MDS to reflect the residents’ conditions. He/She said falls, weight loss, oxygen, and antipsychotics should be indicated on the MDS. He/She said he/she is unsure why Resident #30’s falls were not listed on the MDS, but it may be because they did not see documentation of falls in the resident’s medical record. He/She said he/she is unsure why Resident #37’s weight loss and oxygen are not on the MDS. He/She said he/she is unsure why Resident #67’s antipsychotic is not indicated on the MDS. He/She said they have a hard time finding the information they need to complete the MDSs in the residents’ medical charts. During an interview on 8/21/18 at 9:15 A.M., the DON said the MDS Coordinator fills out the MDS assessments and is expected to fill out the MDS per the RAI guidelines and it should be an accurate reflection of the residents. The DON said falls, weight loss, oxygen use, and [MEDICAL CONDITION] medications should be on the MDS. The DON said the MDS Coordinator is new and had only been there two weeks. He/She is not sure why prior staff did not complete the assessments accurately. | |
| F 0656 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | Develop and implement a complete care plan that meets all the resident’s needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/31/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265530 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER JEFFERSON CITY NURSING AND REHABILITATION CTR, LLC | STREET ADDRESS, CITY, STATE, ZIP 1221 SOUTHGATE LANE | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0656 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 4) -Diagnoses of [MEDICAL CONDITION], hypertension, [MEDICAL CONDITION]; -Shortness of breath with exertion or lying flat; -Used oxygen; -Used a Bilevel Positive Airway Pressure ([MEDICAL CONDITION], a non-invasive form of therapy for patients suffering from sleep apnea) machine; -Did not have any restraints or alarms. Review of the resident’s care plan, undated, showed staff did not address how much oxygen to administer to the resident, and staff did not address the resident’s [MEDICAL CONDITION] machine. Further review showed staff did not address how to monitor the resident for the continued need of or safety of bedrails. Observation on 08/13/18 at 3:00 P.M., showed the resident in bed with 1/4 rails on both sides of his/her bed. Further observation showed the resident had a nasal cannula in place and an oxygen concentrator next to his/her bed. Additional observation showed a [MEDICAL CONDITION] machine on the table next to the resident’s bed. Observation on 08/15/18 at 11:38 A.M., showed the resident in bed with 1/4 rails on both sides of his/her bed. Further observation showed the resident had a nasal cannula in place and an oxygen concentrator next to his/her bed. Additional observation showed a [MEDICAL CONDITION] machine on the table next to the resident’s bed. During an interview on 08/13/18 at 3:00 P.M., the resident said he/she uses the bedrails to help reposition in bed. He/She said he/she is usually on 2-3 liters of oxygen, he/she receives nebulizer treatments, and he/she has a [MEDICAL CONDITION] machine. 3. Review of Resident #7’s quarterly Minimum Data Set (MDS), dated [DATE], a federally mandated assessment, showed staff assessed Resident #7 as: -Cognitively intact without behaviors; -Requires extensive physical assistance of one person for bed mobility, transfers, dressing, toileting, personal hygiene, and bathing; -Impaired range of motion for one upper extremity; -Did not have any restraints. Review of the resident’s care plan, last updated 2/2018, showed staff did not develop and implement measurable goals and interventions to address the resident’s use of side rails or grab bars. Observation on 08/13/18 at 2:47 P.M., showed the resident on his/her back in an electric bed with an air mattress and a half side rail in the raised position on the left and a half side rail in a lowered position on the right. The resident said the right siderail was broken. A pillow was between the rail and the bed. Observation on 08/14/18 at 3:41 P.M., showed the resident in bed on his/her back with the air mattress and siderails in place as previously observed. Observation showed bruising and lacerations on the resident’s face from a fall on the evening of 08/13/18. Observation on 08/15/18 at 09:52 P.M., showed the resident in a low bed with fall mats on both sides. The bed had no siderails, however the resident asked for siderails to assist in repositioning in bed. Observation on 08/21/18 at 10:00 A.M., showed the resident with grab bars on the low bed per his/her request. 4. Review of Resident’s #9’s care plan, dated 2/8/18, showed staff are directed to do the following: -Extensive assistance with all Activities of daily living (ADL); -Please ensure that all ADL needs are met and are met safely; -Need assist of two for bed mobility, dressing, toileting, hygiene, and transfer with mechanical lift. |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/31/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265530 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER JEFFERSON CITY NURSING AND REHABILITATION CTR, LLC | STREET ADDRESS, CITY, STATE, ZIP 1221 SOUTHGATE LANE | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0656 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 5) Further review of the resident’s care plan, dated 2/8/18, showed staff did not develop and implement measurable goals and interventions to address the resident’s use of grab bars. Review of the resident’s MDS, dated [DATE], showed staff assessed the resident as follows: -Moderate cognitive impairment; -Required extensive assistance of two or more staff for bed mobility, transfers, and toileting; -Required extensive assistance of one staff member for dressing, locomotion on unit, personal hygiene, and bathing; -Did not have any falls. Observation on 8/13/18 at 3:55 P.M., showed the resident in bed on his/her back. Observation showed the resident had two grab bars at the head of his/her bed. Observation on 8/15/18 at 8:33 P.M., showed the resident in bed on his/her back. Observation showed the resident had two grab bars at the head of his/her bed. Observation on 8/16/18 at 10:54 A.M., showed the resident in bed on his/her back. Observation showed the resident had two grab bars at the head of his/her bed. During an interview on 8/20/18 at 12:32 P.M., the Director of Nursing (DON) said he/she is not aware the resident had side rails or grab bars on his/her bed. The DON said if the resident’s used side rails/grab bars then he/she would expect it to be on the care plan and he/she is not sure why they were not on the care plan. 5. Review of Resident’s #27’s care plan, dated 05/25/18, showed staff did not develop and implement measurable goals and interventions to address the resident’s use of grab bars. Review of the resident’s MDS, dated [DATE], showed staff assessed the resident as follows: -Moderate cognitive impairment; -Required extensive physical assistance of one person for bathing; -Required limited assistance of one staff member for dressing, toileting, and personal hygiene; -Required set up assistance for locomotion, bed mobility, transfers, and eating; -No falls; -No restraints. Observation on 08/13/18 at 02:39 P.M., showed the resident’s bed to have a grab bar on the left side of the bed. Observation on 08/17/18 at 01:41 P.M., showed the resident lying in bed on his/her left side. A grab bar is in place on the left side of the bed. 6. Review of Resident #30’s MDS, dated [DATE], showed staff assessed the resident’s as follows: -Moderate cognitive impairment; -Required extensive assistance of one staff for bed mobility, transfers, dressing, toilet use, personal hygiene, and bathing. Review of the resident’s Care plan dated 8/13/18, showed that staff documented the resident had a decline in ADL functioning; -Need one person to assist with toileting, hygiene, mobility, transfers and dressing. Further review of the care plan showed staff did not create a care plan to direct staff how/when to shower the resident. 7. Review of Resident #47’s admission Minimum Data Set (MDS), a federally mandated assessment, dated 06/01/18, showed staff assessed the resident as: -Cognitively intact with no behaviors; -Requires limited physical assistance of one person for transfers, ambulating, dressing, toileting, personal hygiene, and bathing; -Requires set up help and supervision for bed mobility and eating; |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/31/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265530 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER JEFFERSON CITY NURSING AND REHABILITATION CTR, LLC | STREET ADDRESS, CITY, STATE, ZIP 1221 SOUTHGATE LANE | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0656 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 6) -Always continent of bladder, occasionally incontinent of bowel; -Diagnoses of [MEDICAL CONDITION], diabetes mellitus, [MEDICAL CONDITION]; -During the seven day look back took insulin injections for seven days and a diuretic for seven days; -No restraints. Additional review of the resident’s MDS history showed the resident has been discharged to the hospital frequently since 02/25/16, with six discharge with return anticipated MDS’s transmitted since admission to this facility on 03/20/18. Review of the resident’s care plan dated 06/01/18, shows the following: -Staff did not address the [DIAGNOSES REDACTED]. -Staff did not provide specific instructions to staff regarding signs and symptoms of hyper/[DIAGNOSES REDACTED] in the care plan. Staff did not provide specific guidelines for contacting the physician regarding blood sugar levels; -Staff did not address the frequent hospitalization s and possible interventions for staff, including to be proactive with notifying the physician with labs, blood sugar levels, and to report when the resident refuses to take medication as prescribed. The care plan does not address the ammonia levels and when the physician should be called with the elevated levels. Review of the hospital discharge summary, dated 07/20/18, showed as criteria for discharge it was reiterated to the resident the need to be taking medications as prescribed every day. The discharge summary also said this information needs to be reiterated with the nursing facility she lives at. During an interview on 08/20/18 at 02:03 P.M., the Nurse Practitioner said the resident is often noncompliant in taking his/her medications as prescribed and he/she expects the care plan to address the need for encouraging the resident to take medications as prescribed. During an interview on 08/20/18 at 12:32 P.M. the DON said the care plan should provide direction for staff if a resident refuses to take a medication, particularly when not taking the medication can lead to hepatic coma. 8. Review of Resident #53’s Quarterly MDS, dated [DATE], showed staff assessed the resident as follows: -Rarely/Never understood; -Behaviors not directed towards others; -Required supervision and set up with eating; -Weight loss. Review of the resident’s care plan, dated 07/2018, showed staff are directed to prevent weight loss by: -Offer snacks; -Provide health shakes as needed (prn) and during medication pass; -Provide finger foods with all meals; -Increase portions of finger foods, super cereal, and 1/2 sandwich for lunch and dinner; –let the resident eat meals with plate on my lap; -Allow the resident to eat at his/her own table; -Serve the resident meals on a plate with a lip or guard; -Follow up with the dietician to evaluate; -Allow the resident ample time to consume food; -Provide assistance with feeding and cueing as needed; -Monitor food intake at each meal and record; -Promptly offer the resident food alternatives when appropriate. Review of the resident’s care plan, dated 07/2018, showed staff are directed to encourage |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/31/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265530 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER JEFFERSON CITY NURSING AND REHABILITATION CTR, LLC | STREET ADDRESS, CITY, STATE, ZIP 1221 SOUTHGATE LANE | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0656 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 7) participation in activities by: -Provide towels and clothes to fold; -Put colorful yarn on the table; -Give a damp cloth to help clean hand rails; -Provide activities with hand manipulation tasks. Observation on 08/13/18 at 11:44 A.M., showed the resident in his/her broda chair alone at a small corner table. Further observation showed the resident’s plate did not include increased portions and was placed on the table. Staff did not implement the care plan instructions by not ensuring increased portions and by not allowing the resident to eat with the plate in his/her lap. Observation on 08/14/18 at 11:36 A.M., showed the resident in his/her broda chair alone at a small corner table. Further observation showed the resident’s plate did not include increased portions and was placed on the table. Staff did not implement the care plan instructions by not ensuring increased portions and by not allowing the resident to eat with the plate in his/her lap. Observation on 08/15/18 at 11:55 A.M., showed the resident in his/her broda chair alone at a small corner table. Further observation showed the resident’s plate did not include increased portions and was placed on the table. Staff did not implement the care plan instructions by not ensuring increased portions and by not allowing the resident to eat with the plate in his/her lap. Observation on 08/15/18 at 12:40 P.M., showed the resident in his/her broda chair alone near a small corner table. Further observation showed the resident scoot to the edge of his/her chair turn backwards and twist the chair tag with his/her hands. Observation on 08/15/18 at 1:55 P.M., showed the resident in his/her broda chair alone near a small corner table. Further observation showed staff did not include the resident in an activity initiated by staff to residents who sat at the tables in the adjoining dining room. Additional observation showed the resident continue to twist the chair tag with his/her hands. Observation on 08/16/18 at 12:03 P.M., showed the resident in his/her broda chair alone at a small corner table. Further observation showed the resident’s plate did not include increased portions and was placed on the table. Staff did not implement the care plan instructions by not ensuring increased portions and by not allowing the resident to eat with the plate in his/her lap. Observation on 08/16/18 at 3:30 P.M., showed the resident awake in his/her wheelchair alone in his/her room. Further observation showed the light was off and there was no television or music on. Staff did not engage the resident in an activity or provide materials to the resident as directed by the care plan. During an interview on 08/16/18 at 3:30 P.M., the Activity Aide said staff provide nail care, adult coloring, and other activities specific to their likes to residents who need one on one attention. He/She said the resident joins them in the living room for Bible Study and exercise ball but he/she mainly watches. He/She said most days the resident exercises by going up and down the hall in his/her wheelchair. The Activity Aide said he/she does not know what activities are listed on the resident’s care plan but he/she knows how to access it. He/She said he/she is unsure why the resident was excluded from the coloring activity. He/She said staff should follow the care plan if they are up-to-date. 9. Review of Resident #67’s Admission MDS, dated [DATE], showed staff assessed the resident as follows: -Rarely/Never understood; |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/31/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265530 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER JEFFERSON CITY NURSING AND REHABILITATION CTR, LLC | STREET ADDRESS, CITY, STATE, ZIP 1221 SOUTHGATE LANE | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0656 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 8) -Did not have behaviors; -Did not have psychiatric or mood disorders; -Did not receive antipsychotic medications; Review of the resident’s POS, dated 07/11/18, showed staff are directed to administer 50mg of [MEDICATION NAME] (antipsychotic) to the resident by mouth each night at bedtime. Review of the resident’s care plan, dated 07/26/2018, showed staff did not address monitoring the resident for the side effects of antipsychotic medication. During an interview on 08/17/18 at 1:15 P.M., Licensed Practical Nurse (LPN) A said he/she has never seen any behaviors from the resident but he/she does wander a little after his/her spouse leaves, and looks for him/her. He/She said according to the POS the resident is on [MEDICATION NAME] for either [MEDICAL CONDITION] or Alzheimer’s but no [DIAGNOSES REDACTED]. During an interview on 08/17/18 at 2:12 P.M., Certified Nurse Assistant (CNA) F said he/she is familiar with the resident. He/She said the resident wanders occasionally and tries to get out the doors to go home after his/her husband leaves. He/She said they redirect with activities, snacks, and one on ones. He/She said the resident has never yelled, hit, or anything like that. He/She does seem a little aggravated when he/she cannot leave because the tone of his/her voice changes. CNA F said he/she has never been instructed or seen directives on the care plan about monitoring residents for side effects of antipsychotics. 10. During an interview on 08/16/18 at 11:20 A.M., CNA E said he/she has been there for eight weeks and to his/her knowledge everyone receives their two showers per week unless they refuse. He/She said aides complete shower sheets to show they have been done and to track skin issues. He/She said they turn them into nursing to monitor. He/She said they get care cards to show what care residents need and they are off the care plans. He/She said nursing updates care plans with changes. During an interview on 08/20/18 at 12:07 P.M., LPN D said the MDS coordinator is responsible to develop resident care plans but nursing staff can update the care plans after falls and other changes in care needs. He/She said all staff are expected to implement the care plan instructions. He/She said the care plans are updated quarterly and as needed. He/She said staff should ask the MDS coordinator if they have a question about implementing the care plan. He/She said falls, skin issues, or any other changes should be updated on the care plans. During an interview on 08/21/18 at 9:12 A.M., the MDS Coordinator said he/she is responsible for developing care plans and he/she tries to ensure they are person centered. He/She said things like bed rails, weight loss, ADL care, hospitalization s, oxygen use, and [MEDICAL CONDITION] medications should be listed on the care plan. He/She said they create care guides for aides when they create and update care plans so the front line staff can know how to care for the resident properly. He/She said he/she is unsure why Resident #1 & #9’s side rails were not addressed in their care plans. The MDS Coordinator said he/she did not know either of them had side rails. He/She said he/she is unsure why the activity interventions for Resident #53 are not being implemented but he/she will ask the activities director. He/She said they try to keep staff updated on the care plans and if they see something not implemented correctly they educate and correct staff in person. He/She is unsure why showers are not addressed on care plans. The MDS Coordinator said he/she does not know why the hospitalization s are not listed on the care plans but he/she thinks that should be on there. He/She said he/she is unsure if Resident #47’s weight fluctuation is on his/her care plan but he/she will review it because it should be on there. He/She said he/she was unaware Resident #53 was not getting his/her |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/31/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265530 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER JEFFERSON CITY NURSING AND REHABILITATION CTR, LLC | STREET ADDRESS, CITY, STATE, ZIP 1221 SOUTHGATE LANE | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0656 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 9) plate in his/her in his/her lap or his/her double portions because he/she does not go to the Memory Care Unit very often. He/She said staff should ask if they have questions about implementing care plan instructions. He/She said he/she has not been putting oxygen liters on care plans but will review all the resident’s receiving oxygen and get them updated. He/She said he/she would have added Resident #67’s antipsychotic to the care plan if it had been coded correctly on the MDS. During an interview on 8/21/18 at 9:15 A.M., the DON said the MDS Coordinator is responsible for creating the care plans and they should accurately reflect the residents and their care needs. The DON said resident care plan should include falls, weight loss, ADLs including showers, [MEDICAL CONDITION] medications, and side rails with interventions for each. | |
| F 0657 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/31/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265530 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER JEFFERSON CITY NURSING AND REHABILITATION CTR, LLC | STREET ADDRESS, CITY, STATE, ZIP 1221 SOUTHGATE LANE | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0657 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 10) -Required extensive assistance of two or more staff for bed mobility and toileting; -Required total assistance of two or more staff for transfers,dressing, locomotion on unit, personal hygiene, and bathing; -No indwelling catheter use; -Frequently incontinent of bowel and bladder. Review of the resident’s care plan, dated 2/8/18, showed staff documented the resident had a foley catheter and staff are directed to do the following: -Monitor and assess for signs/symptoms of infection; -Catheter care every shift; -Secure catheter with leg strap to prevent pulling; -Keep collection bag below bladder level; -Change catheter 16F (french), a type of indwelling catheter, 10 cubic centimetre (cc) or drainage bag based on Centers for Disease Control (CDC) guidelines. Further review of the resident’s care plan, dated 2/8/18, showed staff did not update the resident’s care plan when the resident’s indwelling catheter was discontinued on 8/9/18. Review of the resident’s Physician order [REDACTED].>Review of the resident’s nurse’s notes, dated 8/9/18, showed staff documented the resident was seen in the urology clinic. Staff documented the resident’s catheter was removed at the urology clinic and the resident will need brief changes every two hours and expect him/her to leak small amount of urine frequently. Observation on 8/14/18, at 10:24 A.M., showed the resident did not have a catheter. Observation on 8/16/18 at 10:54 A.M., showed the resident in bed and did not have a catheter. 4. Review of Resident #30’s MDS, dated [DATE], showed facility staff assessed the resident as follows: -Moderate cognative impairment; -Required extensive assistance of one staff for bed mobility, transfers, dressing, toileting, personal hygiene, and bathing; -Did not have any falls. Review of the resident’s nurse’s notes, dated 5/21/18, showed staff documented on 5/19/18 the resident propelled himself/herself down the hallway and slid forward which resulted in the resident falling forward out of his/her wheelchair and landing on the floor. Facility staff documented the resident’s had a 4 inch raised lump above his/her left eye and bruise at left zygomatic arch (cheek), with two skin tears noted, one on each knee. Review of the resident’s MDS, dated [DATE], showed staff assessed the resident’s as the follows: -Moderate cognative impairment; -Required extensive assistance of one staff for bed mobility, transfers, dressing, toileting, personal hygiene; -Did not have any falls. Review of the resident’s care plan, dated 8/3/18, showed the resident is at risk for falls and staff are directed to do the following: -Fall risk very high and monitor for changes; -Refer to therapy if sustain a fall; -Allow to propel in my wheelchair on the unit; -Assist immediately if you see the resident’s ambulating independently; -Wear non-skid shoes or socks on when in wheelchair; -Toilet frequently to aid in preventing falls. Further review showed the resident’s care plan was not updated to show review of the |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/31/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265530 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER JEFFERSON CITY NURSING AND REHABILITATION CTR, LLC | STREET ADDRESS, CITY, STATE, ZIP 1221 SOUTHGATE LANE | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0657 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 11) current interventions or with new interventions related to his/her fall on 5/19/18. 5. During an interview on 08/16/18 at 11:20 A.M., Certified Nurse Assistant (CNA) E said he/she has been there for eight weeks and to his/her knowledge everyone receives their two showers per week unless they refuse. He/She said aides complete shower sheets to show they have been done and to track skin issues. He/She said they turn them into nursing to monitor. He/She said they get care cards to show what care residents need and they are off the care plans. He/She said nursing updates care plans with changes. During an interview on 8/17/18 at 4:54 PM., Licensed Practical Nurse (LPN) G said the MDS Coordinator updates care plans but nurses can update care plans with falls, weight loss, and when catheters are started or discontinued. During an interview on 08/20/18 at 12:07 P.M., LPN D said the MDS coordinator is responsible for developing resident care plans but nursing staff can update the care plans after falls and changes to care needs. He/She said all staff are responsible to implement the care plan interventions. He/She said the care plans are updated quarterly and as needed. He/She said staff should ask MDS if they have a question about implementing the care plan. He/She said falls, skin issues, or any other changes should be updated on the care plans. During an interview on 08/21/18 at 9:12 A.M., the MDS Coordinator said he/she is responsible to update care plans but nurses can do it too. He/She said they update care plans as often as they can but they are also updated along with the MDS assessments. He/She said care plans should be updated with falls, dementia care, [MEDICAL CONDITION] medications, if a catheter is discontinued or with any change in care needs. He/She said sometimes staff do not notify them of changes with the residents so the care plan does not get updated. He/She said they need daily clinical meetings and better communication to make sure updates are not missed. The MDS Coordinator said he/she thought the Director of Nursing (DON) updated Resident #7’s care plan after his/her most recent fall but he/she is not sure. He/She said care plans are updated after altercations and he/she is unsure why Resident #30’s was not updated or why any dementia care interventions were not added. He/She said he/she has not assessed Resident #30 and was unaware of his/her siderails. He/She is unsure of why Resident #9’s care plan was not updated after his/her catheter was discontinued. He/She said he/she was not made aware of it until yesterday. During an interview on 8/21/18 at 9:15 A.M., the DON said he/she expects the MDS coordinator to update care plans and nurses can update care plans as well with changes. The DON said he/she expects falls, weight loss, medication changes, and order changes such as a discontinued catheter to be updated on the care plans. | |
| F 0658 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | Ensure services provided by the nursing facility meet professional standards of quality. Based on observation, interview and record review, facility staff failed to ensure an |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/31/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265530 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER JEFFERSON CITY NURSING AND REHABILITATION CTR, LLC | STREET ADDRESS, CITY, STATE, ZIP 1221 SOUTHGATE LANE | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0658 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 12) -06/23/18: 7:00 A.M. off-going nurse; -06/25/18: 7:00 A.M. on-coming nurse; -06/25/18: 4:00 P.M. off-going nurse; -06/26/18: 3:00 P.M. off-going nurse; -06/28/18: 11:00 P.M. off-going nurse; -06/30/18: 9:00 P.M. on-coming nurse; -06/30/18: 11:00 P.M. off-going nurse; -07/01/18: 3:00 P.M. on-coming nurse; -07/02/18: 11:00 P.M. off-going nurse; -07/03/18: 4:00 P.M. off-going nurse; -07/03/18: 11:00 P.M. on-coming nurse; -07/05/18: 7:00 A.M. on-coming nurse; -07/05/18: 3:00 P.M. off-going nurse; -07/06/18: 11:00 P.M. off-going nurse; -07/08/18: 3:00 P.M. off-going nurse; -07/08/18: 11:00 P.M. on-coming nurse; -07/10/18: 11:00 P.M. on-coming nurse; -07/11/18: 3:00 P.M. off-going nurse; -07/12/18: 4:00 P.M. off-going nurse; -07/13/18: 7:00 A.M. on-coming and off-going nurse; -07/13/18: 3:00 P.M. off-going nurse; -07/15/18: 7:00 A.M. off-going nurse; -07/15/18: 3:00 P.M. off-going nurse; -07/18/18: 7:00 A.M. off-going nurse; -07/19/18: 7:00 A.M. on-coming nurse; -07/20/18: 7:00 A.M. off-going nurse; -07/20/18: 3:00 P.M. off-going nurse; -07/20/18: 11:00 P.M. on-coming nurse; -07/21/18: 3:00 P.M. off-going nurse; -07/23/18: 4:00 P.M. on-coming nurse; -07/24/18: 11:00 P.M. on-coming nurse; -07/25/18: 7:00 A.M. off-going nurse; -07/25/18: 3:00 P.M. off-going nurse; -07/26/18: 7:00 A.M. on-coming nurse; -07/26/18: 3:00 P.M. off-going nurse; -07/27/18: 7:00 A.M. off-going nurse; -07/28/18: 11:00 P.M. off-going nurse; -07/29/18: 7:00 A.M. on-coming nurse; -07/29/18: 3:00 P.M. off-going nurse; -07/29/18: 11:00 P.M. off-going nurse; -07/30/18: 11:00 P.M. on-coming nurse; -07/31/18: 11:00 P.M. on-coming nurse; -08/01/18: 7:00 A.M. on-coming and off-going nurse; -08/01/18: 3:00 P.M. off-going nurse; -08/02/18: 7:00 A.M. on-coming nurse; -08/02/18: 3:00 P.M. off-going nurse; -08/02/18: 11:00 P.M. on-coming nurse; -08/03/18: 7:00 A.M. off-going nurse; -08/03/18: 3:00 P.M. off-going nurse; |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/31/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265530 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER JEFFERSON CITY NURSING AND REHABILITATION CTR, LLC | STREET ADDRESS, CITY, STATE, ZIP 1221 SOUTHGATE LANE | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0658 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 13) -08/03/18: 11:00 P.M. on-coming nurse; -08/04/18: 7:00 A.M. off-going nurse; -08/04/18: 3:00 P.M. on-coming and off-going nurse; -08/04/18: 11:00 P.M. on-coming and off-going nurse; -08/05/18: 7:00 A.M. off-going nurse; -08/05/18: 3:00 P.M. on-coming and off-going nurse; -08/05/18: 11:00 P.M. on-coming nurse; -08/06/18: 7:00 A.M. off-going nurse; -08/06/18: 11:00 P.M. on-coming nurse; -08/07/18: 7:00 A.M. on-coming and off-going nurse; -08/07/18: 3:00 P.M. on-coming and off-going nurse; -08/07/18: 11:00 P.M. off-going nurse; -08/08/18: 7:00 A.M. on-coming nurse; -08/10/18: 7:00 A.M. off-going nurse; -08/11/18: 7:00 A.M. off-going nurse; -08/11/18: 11:00 P.M. on-coming nurse; -08/13/18: 3:00 P.M. on-coming nurse; -08/14/18: 7:00 AM off-going nurse; -08/14/18: 10:30 P.M. on-coming nurse. The staff also failed to document the sheet count on 6/22, 6/25, 6/26, 6/27 (day and night shifts), 6/29, 6/30, 7/4 (day shift), 7/5 (day shift), 7/6 (day shift), 7/11 (night shift), 7/12 (day shift), 7/13, 7/14, 7/15 (day shift), 7/18, 7/19, 7/20 (night shift), 7/21, 7/22, 7/23 (day shift), 7/25, 7/26 (day shift and evening shift), 7/27 (day shift), 7/29 (evening shift and night shift), 8/1 (evening shift and night shift), and 8/2 – 8/12. 2.During an interview on 08/14/18 at 02:10 P.M., Registered Nurse (RN) I said the narcotic count is to be performed at each shift change by the oncoming Certified Medication Technician (CMT)/Charge Nurse and the off going CMT/Charge Nurse. The narcotic count form should be completed. During an interview on 08/14/18 at 02:34 P.M., RN J said the narcotic count is to be performed at each shift change by the oncoming CMT/Charge Nurse and the off going CMT/Charge Nurse. The narcotic count form should be completed and signed. During an interview on 08/14/18 at 02:44 P.M., the Director of Nursing (DON) said staff should count the narcotics at the beginning and end of each shift and the on-coming and off-going staff performing the count should sign the Control Substance Tracking Form. The form should be completed with a card count. | |
| F 0677 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | Provide care and assistance to perform activities of daily living for any resident who is unable. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/31/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265530 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER JEFFERSON CITY NURSING AND REHABILITATION CTR, LLC | STREET ADDRESS, CITY, STATE, ZIP 1221 SOUTHGATE LANE | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0677 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 14) -Did not have mood indicators; -Did not display behaviors; -Extensive assistance of two or more staff with bed mobility, transfers, and toilet use; -Extensive assistance of one or more staff with dressing and personal hygiene; -Independent with eating; -Catheter; -Always continent of bowel; -[MEDICAL CONDITION], hypertension, [MEDICAL CONDITION]; -Shortness of breath with exertion or lying flat; -Oxygen use; -Bilevel Positive Airway Pressure ([MEDICAL CONDITION], a non-invasive form of therapy for patients suffering from sleep apnea) machine. Review of the resident’s medical chart showed staff showered the resident on 07/12/18, 07/18/18, and 08/03/18. Observation on 08/13/18 at 3:00 P.M., showed the resident in bed, and his/her hair appeared greasy and unkempt. Observation on 08/15/18 at 11:38 A.M., showed the resident in bed, and his/her hair appeared greasy and unkempt. During an interview on 08/13/18 at 3:19 P.M., the resident said he/she has only had two showers in the last two months and maybe one bed bath. During an interview on 08/16/18 at 10:51 A.M., the resident said the staff did not ever shower him/her yesterday because they either forgot or ran out of time. During an interview on 08/17/18 at 3:29 P.M., Certified Nurse Assistant (CNA) C said the resident has not been getting his/her showers because they fired all of the shower aides. 2. Review of Resident #30’s MDS, dated [DATE], showed staff assessed the resident as follows: -Moderate cognitive impairment; -Required extensive assistance of one staff for bed mobility, transfers, dressing, toilet use, personal hygiene, and bathing. Review of the resident’s Care plan dated 8/13/18, showed staff documented the resident had a decline in ADL functioning; -Staff are directed to break self care task into smaller pieces; -Do not jump in and do things for the resident’s and allow the resident’s to initiate self care tasks; -Offer cues and reminders to complete task; -Need one person to assist with toileting, hygiene, mobility, transfers and dressing; Review of the resident’s Skin Monitoring: Comprehensive CNA shower review, dated (MONTH) 1-17 (YEAR) , showed staff documented a shower on 8/3/18. Further review showed the resident received one shower out of the 5 scheduled showers. Review of the resident’s medical record, dated (MONTH) 1, (YEAR) through (MONTH) 17, (YEAR), showed staff did not document any shower refusals. 3. Review of Resident #54’s MDS, dated [DATE], showed staff assessed the resident’s as follows: -Moderate cognitive impairment; -Required extensive assistance of one staff for bed mobility, transfer, dressing, toileting, personal hygiene and bathing. Review of the resident’s Skin Monitoring: Comprehensive CNA shower review, dated (MONTH) 5, (YEAR) through (MONTH) 17, (YEAR), showed staff documented the following: -Offered a shower on 8/7/18 and the resident’s said he/she was too tired and will do on |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/31/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265530 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER JEFFERSON CITY NURSING AND REHABILITATION CTR, LLC | STREET ADDRESS, CITY, STATE, ZIP 1221 SOUTHGATE LANE | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0677 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 15) 8/8/17, no nurses signature; -Offered shower on 8/15/18 and said he/she would take a shower 8/16/18, no nurses signature. Further review of the residents Skin Monitoring: Comprehensive shower review, dated (MONTH) 5, (YEAR) thorough (MONTH) 17, (YEAR) showed staff did not reoffer a shower on 8/7/17 or 8/15/17. Review showed the resident did not receive any shower out of the 4 showers he/she should have had. Observation on 8/13/18 at 2:48 P.M., showed the resident’s hair appeared greasy and unkempt. Observation on 8/14/18 at 10:14 A.M., showed the resident’s hair appeared greasy and unkempt. Observation on 8/14/18 at 2:55 P.M., showed the resident’s hair appeared greasy and unkempt. 4. During an interview on 08/16/18 at 11:20 A.M., CNA E said he/she has been there for eight weeks and to his/her knowledge everyone receives their two showers per week unless they refuse. He/She said aides complete shower sheets to show they have been done and to track skin issues. He/She said they turn them into nursing to monitor. 5. During an interview on 8/20/18 at 12:00 P.M., the Administrator said staff completing the showers should document showers on the shower sheets and those are then kept for two weeks. The Administrator said staff are also expected to document showers in the shower book. The Administrator said the Director of Nursing (DON) is to receive the shower sheets every night and once a week the Administrator also looks at the shower book to ensure they are done. The Administrator said the staff don’t always fill out the shower book with showers given. The Administrator said at minimum staff should offer a resident two showers a week and more frequently if wanted. The Administrator said if the resident refuses staff should fill out a refusal form and have the nurses make a second attempt and sign the form. 6. During an interview on 08/20/18 at 12:07 P.M., Licensed Practical Nurse (LPN) D said residents get showers two or three times a week unless they request more often. He/she said the aides are expected to document showers on sheets and nursing reviews and signs off on them so if there are any skin issues they can be addressed. He/She is unsure why some residents do not have shower sheets, and said since he/she is agency staff, he/she does not know why. 7. During an interview on 8/20/18 at 12:32 P.M., the DON said the residents should be offered a shower at minimum two times a week. The DON said if the resident refuses then staff should write it down and have the nurse try again. The DON said that staff should document showers on the shower sheets and shower books. CNAs are assigned to showers each shift by the charge nurse. The DON said the charge nurse is expected to follow up to ensure the showers are done each day. The DON said he/she is not sure if anyone is monitoring to ensure showers are done. MO 423 | |
| F 0684 Level of harm – Actual harm Residents Affected – Few | Provide appropriate treatment and care according to orders, resident’s preferences and goals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/31/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265530 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER JEFFERSON CITY NURSING AND REHABILITATION CTR, LLC | STREET ADDRESS, CITY, STATE, ZIP 1221 SOUTHGATE LANE | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0684 Level of harm – Actual harm Residents Affected – Few | (continued… from page 16) hospital discharge orders for daily weights and leg measurements to monitor fluid overload due to [MEDICAL CONDITION] over to the physician’s orders [REDACTED].#1) who required admission and treatment in the hospital. The facility census was 75. 1. Review of Resident #1’s admission Minimum Data Sheet (MDS), a federally mandated assessment tool, dated 03/12/18, showed staff assessed the resident as follows: -Cognitively intact; -Did not have any mood indicators; -Did not have any behaviors; -Required extensive assistance of two or more staff with bed mobility, transfers, and toilet use; -Required extensive assistance of one or more staff with dressing and personal hygiene; -Independent with eating; -[DIAGNOSES REDACTED]. -Shortness of breath with exertion or lying flat; -Received an anti depressant 7 days per week; -Used oxygen; – Bilevel Positive Airway Pressure ([MEDICAL CONDITION], a non-invasive form of therapy for patients suffering from sleep apnea) machine. Review of the resident’s hospital discharge orders, dated 08/07/18, showed staff are directed to administer oxygen at 4 liters per minute by nasal cannula when at rest and 6 liters per minute during activities, weigh the resident daily and notify the physician with changes in weight for more than three pounds in a day or five pounds in a week. Further review showed staff are directed to administer the [MEDICAL CONDITION] as ordered. Additional review showed staff are directed to check as needed (PRN) for respiratory distress or a change in the resident’s condition per nurse assessment. Review of the resident’s nurses’ notes, dated 08/07/18, showed staff documented the resident readmitted to the facility from the hospital for chronic [MEDICAL CONDITION], all previous care orders and medications to continue, and staff are directed to weigh the resident daily before breakfast and notify the doctor of a three pound weight difference in one day and a five pound difference in a week. Review of the resident’s physician’s orders [REDACTED]. Review of the resident’s Medication Administration Record [REDACTED]. Further review showed staff did not transcribe the order to complete daily weights on the MAR indicated [REDACTED]. Additional review showed staff documented they administered [MEDICATION NAME] (antianxiety medication) to the resident on 08/15/18 at 2:15 P.M. and on 08/16/18 at 3:45 P.M. for anxiety, but did not document follow-up to show if the medication was effective. Review of the resident’s physician’s orders [REDACTED]. Further review showed staff are directed to administer [MEDICATION NAME] 2.5mg every six hours PRN for shortness of breath. Additional review showed staff did not transfer the following hospital discharge orders, dated 08/07/18 to the resident’s current POS: -Weigh the resident daily and notify the physician with changes in weight for more than three pounds in a day or five pounds in a week; -[MEDICAL CONDITION] administration instructions; -Check for respiratory distress PRN. Observation and interview on 08/13/18 at 3:00 P.M., showed the resident lie in bed with a nasal cannula in place and an oxygen concentrator next to his/her bed. Additional observation showed a [MEDICAL CONDITION] machine on the table next to the resident’s bed. The resident said he/she is usually on 2-3 liters of oxygen, he/she receives nebulizer treatments, and he/she has a [MEDICAL CONDITION] machine. He/She said the [MEDICAL |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/31/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265530 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER JEFFERSON CITY NURSING AND REHABILITATION CTR, LLC | STREET ADDRESS, CITY, STATE, ZIP 1221 SOUTHGATE LANE | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0684 Level of harm – Actual harm Residents Affected – Few | (continued… from page 17) CONDITION] machine has not been working and he/she has been trying to contact the supplier for help. Review of the resident’s weight change history, dated 08/15/18, showed staff documented the following: -528 lbs. on 08/03/18 -529 lbs. on 08/09/18. Additional review showed staff did not document weights for 08/10/18, 08/11/18, 08/12/18, 08/13/18, 08/14/18, 08/15/18, and 08/16/18. During an interview on 08/16/18 at 6:00 P.M., the Corporate Advisor said he/she is not sure where staff documented the resident’s daily weights but they should be listed on the TAR. During an interview on 08/16/18 at 6:00 P.M., the Corporate Vice President said the hospital discharge orders do list daily weights under general instructions but those are blanket instructions for all discharge orders so staff did not transfer them over to the resident’s POS. Review of the resident’s nurses’ notes, dated 08/17/18 late entry for 8/16/18, showed staff documented the resident was short of breath, assessment done, and treatment given. Further review showed staff administered [MEDICATION NAME] for anxiety and called the physician for orders to send the resident to the hospital. Observation on 08/15/18 at 11:38 A.M., showed the resident lie in bed with a nasal cannula in place and an oxygen concentrator next to his/her bed. Additional observation showed a [MEDICAL CONDITION] machine on the table next to the resident’s bed. Observation and interview on 08/15/18 at 8:19 P.M., showed the resident lie in bed with nasal cannula in place connected to a portable oxygen tank. Further observation showed the resident took deep breaths when he/she spoke. Additional observation showed the filter on the oxygen concentrator clogged with debris. The resident said his/her oxygen concentrator is not working so staff brought him/her a portable tank. He/She said he/she is having trouble breathing and he/she thinks it is because he/she is on a portable tank instead of an oxygen concentrator. He/She said he/she has not been weighed today. Observation and interview on 8/16/18 at 3:30 P.M., showed the resident lie in bed with nasal cannula in place. He/She appeared to struggle to breathe and had a difficult time talking due to shortness of breath. He/She had the oxygen concentrator at eight liters. He/She had his/her own pulse oximeter and was monitoring his/her oxygen saturation level. Certified Nurse Assistant (CNA) C entered the room and helped the resident put on his/her [MEDICAL CONDITION] mask to see if it would help but the resident’s oxygen saturation level dropped to 67%. The resident removed the [MEDICAL CONDITION] and put the nasal cannula back on with the oxygen set at eight liters. Survey staff from Department of Health and Senior Services (DHSS) intervened and asked CNA C to get a nurse and let them know the resident was having trouble breathing. Licensed Practical Nurse (LPN) G entered the room and observed the resident. The LPN did not listen to the resident’s lung sounds, take the resident’s vital signs, or complete an assessment. The resident said he/she is having trouble keeping his/her oxygen saturation level above 90% even with the oxygen set at eight liters. Observation and interview on 08/16/18 at 3:53 P.M., showed the resident lie in bed with nasal cannula in place connected to the concentrator set at eight liters. Further observation showed the resident using an oximeter to track his/her oxygen saturation. Additional observation showed the resident take deep breaths and struggled to talk. His/Her oxygen saturation was at 89%. LPN G entered the room and looked at the resident’s oxygen saturation reading on the oximeter and said it had improved. The resident said |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/31/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265530 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER JEFFERSON CITY NURSING AND REHABILITATION CTR, LLC | STREET ADDRESS, CITY, STATE, ZIP 1221 SOUTHGATE LANE | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0684 Level of harm – Actual harm Residents Affected – Few | (continued… from page 18) his/her oxygen saturation level is at 90% with eight liters of oxygen but he/she still feels like he/she cannot breathe. He/She said he/she wants his/her [MEDICAL CONDITION] to work but the person from the respiratory care supplier is not at the facility. LPN G said he/she does not know how to work the machine but he/she thinks the facility has a contract with a respiratory therapist. LPN G did not take the resident’s vitals, check his/her lung sounds, or assist with his/her [MEDICAL CONDITION] machine. During an interview on 08/16/18 at 3:53 P.M., LPN G said he/she is unsure whether the resident has a [MEDICAL CONDITION] or [MEDICAL CONDITION] and he/she does not know if it is working or not. He/She said he/she thinks they contract with a respiratory therapy company to help with the equipment. He/She said the resident’s oxygen level seems to be coming up from earlier. During an interview on 8/16/18 at 4:50 P.M., LPN G said he/she knew the resident was having difficulty breathing and he/she had given him/her an [MEDICATION NAME] (anxiety medication). When asked if he/she had assessed the resident LPN G said no because he/she was passing medications so the charge nurse would have done the assessment. During an interview on 8/16/18 at 4:53 P.M., LPN H (the charge nurse) said he/she had not assessed the resident because he/she thought LPN G had done it before he/she gave the resident medication. During an interview on 8/16/18 at 4:55 P.M., the Director of Nursing (DON) said he/she was just informed of the situation. The DON said he/she asked LPN G to go now and assess the resident and listen to his/her lungs. During an interview on 8/16/18 at 4:59 P.M., LPN G said the resident’s lungs sounded clear. He/She said staff did not contact the physician about the resident’s shortness of breath. During an interview on 8/16/18 at 5:00 P.M., the resident said staff did not complete daily weights on him/her. Observation on 08/16/18 at 5:05 P.M., showed staff did not contact the physician about the resident’s decreased oxygen saturation level and difficulty breathing until this time, and the physician directed staff to send the resident out to the hospital. Review of the resident’s emergency department records, dated 8/16/18, showed the following: -Chief complaint of respiratory distress: increased shortness of breath; -Was discharged from our facility about 1 week ago after an admission with acute on chronic [MEDICAL CONDITION] and was [MEDICATION NAME] (increase urine excretion) and discharged on increased dose of [MEDICATION NAME] (a water pill that treats fluid build-up due to heart failure or kidney disease); -The resident’s stated that 1st day or 2 after leaving the hospital he/she did pretty well and then last couple days his/her shortness of breath has worsened. States that today they placed her/him from nasal cannula onto a [MEDICAL CONDITION] and his/her oxygen saturations dropped down to 60%; -The resident said that he/she is not sure that the oxygen and entire machine is hooked up correctly; -Weight 545 lbs (247.2 kg); -Sp 02 (blood saturation of oxygen) at 93%; -blood gases arterial: pc02 arterial 62 (high carbon [MEDICATION NAME] in the blood); p02 arterial 63 (low oxygen in the blood), oxygen saturation 91 (low), HCO3 ([MEDICATION NAME] -maintains the body’s pH) arterial 34 (High); base excess arterial 6.6 (high), TC02 (total carbon [MEDICATION NAME] in the blood) arterial 36 (high); -admitted for IV (intravenous or through the bloodstream) diuresis and further evaluation |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/31/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265530 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER JEFFERSON CITY NURSING AND REHABILITATION CTR, LLC | STREET ADDRESS, CITY, STATE, ZIP 1221 SOUTHGATE LANE | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0684 Level of harm – Actual harm Residents Affected – Few | (continued… from page 19) care; -Final Diagnoses: [REDACTED]. Review of the resident’s hospital records, admitted [DATE] and expected discharge date of [DATE], showed the resident was admitted and hospital staff documented the following: -Diagnosis: [REDACTED]. -Weight 545 pounds; -C02 30mmol/L (high) on 8/18/18; -Chest x-ray 8/16/18 diffuse severe airspace disease, similar in appearance to the previous exam on 8/3/18; -Discharge Diagnosis: [REDACTED]. -Following admission IV diuresis and [MEDICAL CONDITION] was provided with significant results within 24 hours. At time of discharge, the resident’s was at his/her baseline cardiopulmonary status. This is concerning for an environmental effect as this is a recurrent pattern of markedly improving within 24-48 hours of hospitalization . We spoke about habits and care at the facility. Education was provided. Further review of the resident’s hospital records, admitted [DATE] and discharge date [DATE], showed the following physician orders [REDACTED].>-Oxygen saturation – check as needed for respiratory distress or change in patients condition per Registered Nurse (RN) assessment; -Notify physician of respirations per minute greater than 28 or less than 12; -Notify physician if patients weight increases or decreases by 3 lbs in one day or 3 lbs in one week; -Oxygen at 3-4 L/minute by nasal cannula continuously; -[MEDICAL CONDITION] at bedtime per specific setting orders until late into the morning every day; and as needed with naps; -[MEDICATION NAME]: 80 mg tablet one tablet by mouth two times a day; -Continue taking [MEDICATION NAME] 0.083% nebulizer solution inhale 2.5mg by mouth every 6 hours as needed for shortness of breath or wheezing. Further review of the resident’s hospital records, admitted [DATE] and discharge date on 8/18/18, showed the physician documented the resident has had multiple admissions and is close to baseline after [MEDICAL CONDITION] and initial management. The physician documented he/she discussed the resident’s current setup and schedule of [MEDICAL CONDITION] and oxygen sustentation at the nursing home and there appears to be an issue with his/her home [MEDICAL CONDITION] and then he/she got into trouble. Further review of the resident’s hospital records, admitted [DATE] and discharge date [DATE], showed the social worker documented the resident said he/she had an issue operating their [MEDICAL CONDITION] at the facility. The resident said he/she called the respiratory care supplier to come out and check the [MEDICAL CONDITION] but had not gotten a response. The social worker documented he/she called the supplier and the social worker at the facility notifying them of the issue with [MEDICAL CONDITION]. Further review of the resident’s hospital records, showed the Chaplain documented on 8/17/17 that the resident said if the nursing home would just keep up with his/her weight and medication he/she wouldn’t have to keep returning to the hospital. During an interview on 08/17/18 at 8:30 A.M., hospital staff said the resident was admitted for acute chronic [MEDICAL CONDITION] with hypercapnia (elevated carbon [MEDICATION NAME] levels in the body). He/She said the resident was 545 pounds upon admission and his/her carbon [MEDICATION NAME] level was 60 (Normal carbon [MEDICATION NAME] levels are 23 -29). During an interview on 08/17/18 at 3:29 P.M., CNA C said he/she is very familiar with the |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/31/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265530 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER JEFFERSON CITY NURSING AND REHABILITATION CTR, LLC | STREET ADDRESS, CITY, STATE, ZIP 1221 SOUTHGATE LANE | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0684 Level of harm – Actual harm Residents Affected – Few | (continued… from page 20) resident. He/She said staff weigh the resident only when the Registered Dietician asks but he/she knows staff are supposed to do it every morning. He/She said the resident told him/her the day staff was not doing his/her daily weights. He/she said the resident went out to the hospital last week because his/her weight went up and he/she could not breathe. He/She said the resident called the ambulance himself/herself last time. He/She said the resident told him/her that he/she was having trouble breathing for three days. CNA C said he/she went and got the nurse each time. He/She said the nurse would take the resident’s blood pressure and check his/her oxygen saturation levels but nothing else. He/She never saw staff listen to the resident’s lungs. He/She said the resident struggled for breath every time he/she went in to care for him/her. He/She said the resident asked him/her to turn his/her oxygen to eight even though it is supposed to be at six. He/she said the resident told him/her he/she thinks the portable oxygen tanks work better than the concentrator does. During an interview on 08/17/18 at 3:57 P.M., LPN G said he/she has worked here for two weeks. He/She said he/she is somewhat familiar with the resident. He/She said the resident’s daily weights are done on day shift and he/she has never worked on day shift prior to yesterday so he/she does not know if they are being done or not. He/She said staff use the great big lift to weigh the resident. He/She said the weights are documented in his/her chart probably on the TAR. He/She said the hospital ordered daily weights on 8/7/18 because he/she had gained a lot of weight. He/She said he/she was here when the resident went out last time. He/She said the resident called 911 him/herself. He/She believes staff assessed the resident that time then came down to call for an ambulance but the resident called first. He/She said staff was calling the ambulance due to low oxygen saturation levels. He/She said staff would have contacted the physician for orders to send the resident out if he/she wouldn’t have called himself/herself. He/She said staff should have documented the resident’s condition and that he/she called 911 and went to the hospital and he/she is unsure why it was not documented. He/She said yesterday no one notified him/her the resident had trouble breathing but LPN H was the charge nurse so he/she followed him/her down to the resident’s room. He/She said the physician should be contacted if the resident’s oxygen level falls below 90 without correction with oxygen. He/She said the resident is supposed to be on 4 liters while in bed and up to 6 liters with exertion. He/She said the resident may be able to get 6 liters and increase it to 8 himself/herself. He/She said a new concentrator was brought in last week because it went up to 10 liters. He/She said if a resident does have an order for [REDACTED]. He/She said the resident was gasping for breath and thought the [MEDICATION NAME] might help the resident take slower steady breaths. He/She was keeping an eye on the resident’s breathing after he/she administered the [MEDICATION NAME]. He/She said a nebulizer treatment had been given an hour prior to when he/she administered the [MEDICATION NAME]. He/She said the treatment should have been documented he/she said the previous staff member only told him/her about the treatment during report. He/She said the previous staff member did not mention any respiratory distress during report. He/She said the physician should be notified if the facility is unable to take care of the resident using the orders and tools they have available. He/She did asked the resident if he/she wanted to be sent out and he/she said no. He/She said staff should listen to the resident’s lungs during any assessment. He/She said he/she is unsure who maintains the concentrators. He/She said he/she is unsure if the resident’s [MEDICAL CONDITION] is broken or not. During an interview on 08/17/18 at 4:23 P.M., the DON said the resident did have an order for [REDACTED]. He/She said staff weigh the resident between 6-7 A.M. every morning so they can have night and day shift both available to help. He/She said staff used the |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/31/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265530 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER JEFFERSON CITY NURSING AND REHABILITATION CTR, LLC | STREET ADDRESS, CITY, STATE, ZIP 1221 SOUTHGATE LANE | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0684 Level of harm – Actual harm Residents Affected – Few | (continued… from page 21) bariatric lift to weigh the resident and they tell the nurse who documents on the TAR. He/She said the bariatric lift is working as far as they know. He/she said the resident called EMS herself last week due to being short of breath and becoming anxious. He/She said the past hospital stay should be documented in nurse’s notes. He/She is unsure why the last hospital visit was not documented. He/she is unsure if staff contacted the physician the last time the resident was sent out but if he/she was it should be documented. He/She said the nurses make sure the hospital orders are carried over to the current POS and he/she is responsible for reviewing them to make sure everything is transferred over correctly. He/She said staff did not report the resident having shortness of breathe yesterday. He/She expects staff to assess them listen to lungs, use oximeter to check oxygen saturation, and call the doctor if needed for residents reporting shortness of breathe. He/She said staff should contact the physician if they cannot get oxygen levels up or if the order says to. He/she staff should call the physician to clarify and get a specific order for the liter flow of oxygen needed. He/She said staff should follow policy due to how many liters per nasal cannula and he/she does not know why they did not. Review of the respiratory care supplier’s documentation on 8/20/18, showed the supplier |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/31/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265530 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER JEFFERSON CITY NURSING AND REHABILITATION CTR, LLC | STREET ADDRESS, CITY, STATE, ZIP 1221 SOUTHGATE LANE | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0684 Level of harm – Actual harm Residents Affected – Few | (continued… from page 22) CONDITION] because it cannot push air through. He/She said staff should contact his/her office if the resident is having shortness of breath and let them know if the resident needs more than the six liters of oxygen on his/her POS. He/She said staff should have assessed the resident by listening to his/her lungs, counting his/her respiratory rate, check his/her oxygen saturations, and check for speech dyspnea if his/her oxygen saturation dropped into the 60’s. He/She said he/she was in the facility the day the resident was sent to the hospital but no one made him/her aware the resident was having trouble breathing. He/She said if staff would have notified him/her he/she could have assessed the resident. He/She said the hospitalization could have been avoided if the staff had weighed the resident daily and notified him/her. He/She said not monitoring the resident’s weight could result in death since he/she is respiratory compromised and is dependent on daily weights. | |
| F 0689 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/31/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265530 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER JEFFERSON CITY NURSING AND REHABILITATION CTR, LLC | STREET ADDRESS, CITY, STATE, ZIP 1221 SOUTHGATE LANE | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0689 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 23) Staff did not address the resident’s air mattress, bed height, or prior falls on the care plan. Review of the resident’s quarterly Minimum Data Set (MDS), dated [DATE], a federally mandated assessment, showed staff assessed the resident as: -Cognitively intact with no behaviors; -Requires extensive physical assistance of one person for bed mobility, transfers, dressing, toileting, personal hygiene, and bathing; -Requires limited assistance and set up for eating; -Impaired range of motion for one upper extremity; -Always incontinent of bowel and bladder; -[DIAGNOSES REDACTED]. -Takes a scheduled pain medication and reports occasional pain; -On a physician ordered weight loss regimen with a weight of 207 pounds; -During a seven day look back period received seven days of an antipsychotic medication, an anxiolytic (anti anxiety) medication, an antidepressant medication, and an opiod; -No restraints. Review of the resident’s Fall Assessments, dated 08/08/17 and 05/21/18 showed staff assessed the resident to have a score of 40 (low to moderate risk). This score would indicate the staff should implement standard fall prevention interventions. Review of the Incident Log, dated 05/26/18 – 08/13/18, showed staff documented the resident had a fall on 05/26/16, a fall on 01/30/17, and a fall on 08/13/18. Review of the Resident Incident Report, dated 08/13/18, showed staff documented the resident’s bed was in the up position and he/she has a fall history. Observation on 08/13/18 at 02:47 P.M., showed the resident lying on his/her back on an air mattress in an electric bed which was at an elevated height, not the lowest position the bed is capable of. Observation showed a quarter side rail in the upright position on the left. The right side rail was broken, per the resident, and a pillow was tucked in the lowered rail on the right. No fall mats were observed on the floor. Observation also showed the resident does not have half side rails and uses grab bars for positioning. Observation also showed the resident does not use a trapeze. Observation on 08/14/18 at 03:41 P.M., showed the resident on his/her back on an air mattress on an electric bed at an elevated height. The resident’s face showed widespread bruising with a laceration in the right nose/lip area and another laceration in the left cheek/ear area related to a fall on 08/13/18. The right quarter side rail is in the upright position. During an interview on 08/14/18 at 10:56 A.M., the resident said just prior to the fall he/she was asleep and woke as he/she was sliding off the bed. The resident said she couldn’t do anything to stop the fall and fell on his/her face. The resident said no fall mats were on the floor. The resident said it felt like the air mattress had filled up too much, causing him/her to slide off. The resident said the air mattress had been acting up and he/she had been told the facility would be getting a different air mattress but never did. The resident also said he/she had reported the right siderail was broken and it had not been repaired. The resident said he/she was sent to the emergency room for x-rays and care for the lacerations. During an interview on 08/14/18 at 03:41 P.M., the resident’s family members were crying and said the resident has had many falls and has fallen out of the bed at least five times, two with injury. The family member said he/she has requested staff provide a low bed for months. The family member said the resident’s bed is always at a higher level and the family does not know why the resident is not in a low bed. |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/31/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265530 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER JEFFERSON CITY NURSING AND REHABILITATION CTR, LLC | STREET ADDRESS, CITY, STATE, ZIP 1221 SOUTHGATE LANE | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0689 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 24) During an interview on 08/14/18 at 03:50 P.M., the resident’s roommate said she likes her bed high and that the resident’s bed is usually raised as high as hers. During an interview on 08/20/18 at 12:32 P.M., the Director of Nursing (DON) said when a resident falls, the staff should assess the resident for injury. The DON said he/she only knows about the falls listed on the Fall Report Sheet. | |
| F 0700 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/31/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265530 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER JEFFERSON CITY NURSING AND REHABILITATION CTR, LLC | STREET ADDRESS, CITY, STATE, ZIP 1221 SOUTHGATE LANE | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0700 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 25) Review of the resident’s care plan, dated 03/2018, did not address the use of quarter bedrails. Review of the resident’s complete medical record showed no consent for the use of bedrails and no entrapment assessment. Observation on 08/13/18 at 3:00 P.M., showed the resident lie in bed with quarter bedrails on both sides of the bed. Observation on 08/15/18 at 11:38 A.M., showed the resident lie in bed with quarter bedrails on both sides of the bed. Observation on 08/15/18 at 8:19 P.M., showed the resident lie in bed with quarter bedrails on both sides of the bed. Observation on 8/16/18 at 3:30 P.M., showed the resident lie in bed with quarter bedrails on both sides of the bed. Observation on 08/16/18 at 3:53 P.M., showed the resident lie in bed with quarter bedrails on both sides of the bed. During an interview on 08/13/18 at 3:00 P.M., the resident said he/she uses the bedrails to help reposition in bed. He/She said staff has never measured his/her bed. During an interview on 08/20/18 at 12:32 P.M., the Director of Nursing (DON) said he/she is unsure if Residents #1 has bedrails or not. 3. Review of Resident’s #9’s MDS, dated [DATE], showed staff assessed the resident’s as follows: -Moderate cognitive impairment; -Required extensive assistance of two or more staff for bed mobility, transfers, and toileting; -Required extensive assistance of one staff member for dressing, locomotion on unit, personal hygiene, and bathing; -No falls. Review of the resident’s care plan, dated 2/8/18, showed facility staff were directed to do the following: -Extensive assistance with all Activities of daily living (ADL); -Please ensure that all my ADLs needs are met and are met safely; -Need assist of two for bed mobility, dressing, toileting, hygiene, and transfer with hoyer lift. Review of the resident’s side rail screening dated 4/16/18, showed staff documented the resident did not use side rails. Review of the resident’s Physician order [REDACTED]. Review of the resident’s medical record showed it did not contain an entrapment assessment or an informed consent for the use of side rails or grab bars. Observation on 8/13/18 at 3:55 P.M., showed the resident had two grab bars in the raised position on his/her bed. Observation on 8/15/18 at 8:33 P.M., showed the resident in bed with two grabs in the raised position on his/her bed. Observation on 8/16/18 at 10:54 A.M., showed the resident in his/bed with two grab bars in the raised position on his/her bed. During an interview on 8/20/18 at 12:32 P.M., the DON said he/she was not sure if the resident used side rails or grab bars. 4. Review of Resident #17’s admission MDS, dated [DATE], showed staff assessed the resident required set up assistance with supervision for bed mobility and transfers. The MDS does not address the use of siderails. Observation on 08/13/18 at 02:39 P.M., showed the resident’s bed has a grab bar on the |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/31/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265530 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER JEFFERSON CITY NURSING AND REHABILITATION CTR, LLC | STREET ADDRESS, CITY, STATE, ZIP 1221 SOUTHGATE LANE | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0700 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 26) left. Observation on 08/17/18 at 1:41 P.M., showed the resident lying in bed on his/her left side with a grab bar on the left. Further review of the resident’s medical record showed staff did not complete a required entrapment assessment or obtain informed consent for the use of side rails. 5. Review of Resident #54’s MDS, dated [DATE], showed staff assessed the resident as follows: -Moderate cognitive impairment; -Required extensive assistance of one staff for bed mobility, transfer, dressing, toileting, personal hygiene and bathing; -No falls. Review of the resident’s care plan, dated 2/8/18, showed facility staff were directed to do the following: -Use 1/2 side rail for position and transfer to promote independence; -Reposition resident with assistance of two person assist and half side rail; -Encourage participation self care; -Bilateral quarter horseshoe rails as enabler to assist with turning, repositioning, transfer, and promote independence; -Reinforce use of assistance device/enabler and praise when used properly. Review of the resident’s POS, dated (MONTH) (YEAR), showed staff did not document an order for [REDACTED].>Review of the resident’s side rail evaluation, updated 5/21/18, showed the resident used bilateral (both sides) quarter horseshoe rails as an enabler. Review of the resident’s medical record showed it did not contain an entrapment assessment or an informed consent for the use of side rails or grab bars. Observation on 8/13/18 at 2:48 P.M., showed the resident in his/her bed with two grab bars in the raised position on his/her bed. Observation on 8/14/18 at 2:55 A.M., showed the resident in his/bed with two grab bars in the raised position on his/her bed. During an interview on 8/20/18 at 12:32 P.M., the DON said the resident does not use side rails or grab bars. 6. During an interview on 08/17/18 at 1:39 P.M., the Maintenance Assistant said his/her department makes sure beds are safe by making sure the brakes work, they have head board and foot board, and that motors work and parts are intact. He/She said he/she reviews the resident paperwork to make sure they need bedrails and that they are attached to the bed properly. He/She said the facility only uses horseshoe bedrails in the facility so they do not have to be measured. He/She said Resident #1 only has quarter bedrails because the horseshoe rails will not fit the bariatric bed. He/She said he/she did not measure the rails for safety because they were not considered a restraint. He/She said he/she assessed Resident #58’s bed for safety just last night because his/her headboard was off the track. He/She said he/she checks beds for safety monthly but does not document it anywhere. He/She does not add any bedrails until residents and beds are assessed and he/she receives the report from therapy. He/She said they would measure for risk of a resident’s head getting trapped but they switched to the horseshoe bedrails so that is not possible. During an interview on 8/20/18 at 12:32 P.M., the DON said that staff should do restraint assessments, a signed consent, and a physicians order for use of side rails or grab bars. The DON said the restraint assessments should be done quarterly and as needed. The DON said staff do not do entrapments assessments and was not aware that entrapment assessments were required. |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/31/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265530 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER JEFFERSON CITY NURSING AND REHABILITATION CTR, LLC | STREET ADDRESS, CITY, STATE, ZIP 1221 SOUTHGATE LANE | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0700 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | ||
| F 0758 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, facility staff failed to obtain an appropriate |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/31/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265530 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER JEFFERSON CITY NURSING AND REHABILITATION CTR, LLC | STREET ADDRESS, CITY, STATE, ZIP 1221 SOUTHGATE LANE | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0758 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 28) -Cognitively intact; -Moods nearly every day; -No behaviors; -Extensive assistance of two or more staff with bed mobility, transfers, and toileting; -Extensive assistance of one or more staff with dressing and personal hygiene; -Supervision and setup with eating; -Anxiety and depression; -Antidepressant seven days per week. Review of the resident’s POS, dated 08/01/18, showed staff are directed to administer 50mg of Trazadone (antidepressant) once a day at bedtime for depressive episodes, .5mg of [MEDICATION NAME] (antianxiety) once a day at lunch for anxiety, and 10mg of [MEDICATION NAME] (antianxiety) three times a day for anxiety. Review of the pharmacist’s Medication Review Communication, dated 04/19/18, showed the pharmacist suggested a GDR of the .5mg of [MEDICATION NAME] and the 10mg of [MEDICATION NAME]. Additional review showed the physician disagreed with the pharmacist’s suggestion and noted, GDR disaster in past on 06/21/2018. Review of the resident’s complete medical record showed staff did not document a previous GDR attempt. Observation on 08/15/18 at 9:22 P.M., showed the resident lie in his/her bed. He/She was awake, alert, and oriented. During an interview on 08/17/18 at 11:00 A.M., the Acting Administrator said the facility is unable to provide any documentation of a prior GDR attempt. 4. Review of Resident #41’s MDS, dated [DATE], showed staff assessed the resident as follows: -No cognitive impairment; -7 days of antianxiety and antidepressant medications. Review of the Resident’s pharmacist Medication Regimen Review Communication, dated 11/14/17, showed the pharmacist recommenced a GDR of [MEDICATION NAME] (antianxiety medication) one milligram (mg) twice a day [MEDICATION NAME] (antidepressant medication) 100 mg every day. Further review showed there was no response or signature from the resident’s physician. Review of the resident’s POS, dated (MONTH) (YEAR), showed an order for [REDACTED]. During an interview on 8/20/18 at 12:32 P.M., the Director of Nursing (DON) said he/she does not know who the resident is and not sure why the physician did not respond to the GDR recommendation on 11/14/17. 5. Review of Resident #67’s face sheet, dated 07/11/18, showed the resident admitted to the facility with the following Diagnoses: [REDACTED]. -Essential hypertension; -Other chronic pain; -Unspecified symbolic dysfunctions. Review of the resident’s Admission MDS, dated [DATE], showed staff assessed the resident as follows: -Rarely/never understood; -No behaviors; -Wanders less than every day; -Limited assistance of one or more staff for bed mobility, transfers, dressing, toilet use, and personal hygiene; -Independent with set up for eating; -Always continent of bowel and bladder; |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/31/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265530 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER JEFFERSON CITY NURSING AND REHABILITATION CTR, LLC | STREET ADDRESS, CITY, STATE, ZIP 1221 SOUTHGATE LANE | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0758 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 29) -No psychiatric or mood disorders; -No antipsychotic medications. Review of the resident’s POS, dated 07/11/18, showed staff are directed to administer 50mg of [MEDICATION NAME] (antipsychotic) to the resident by mouth each night at bedtime. Staff did not document a [DIAGNOSES REDACTED]. Review of the resident’s care plan, dated 07/26/2018, showed staff did not address the use of antipsychotic medication or to monitor for possible side effects. Observation on 08/13/18 at 11:20 A.M., showed the resident visit with his/her spouse in his/her room. He/She was able to participate in some conversation. During an interview on 08/17/18 at 1:15 P.M., Licensed Practical Nurse (LPN) A said he/she has never seen any behaviors from the resident but he/she does wander a little after his/her husband leaves looking for him/her. He/She said according to the POS the resident is being given [MEDICATION NAME] for either [MEDICAL CONDITION] or Alzheimer’s but no [DIAGNOSES REDACTED]. During an interview on 08/17/18 at 2:12 P.M., Certified Nurse Assistant (CNA) F said he/she is familiar with the resident. He/She said the resident wanders occasionally and tries to get out the doors to go home after his/her husband leaves. He/She said they redirect with activities, snacks, and one on ones. He/She said the resident has never yelled, hit, or anything like that. He/She does seem a little aggravated when he/she cannot leave because the tone of his/her voice changes. He/She said he/she has never been instructed or seen directives on the care plan about monitoring residents for side effects of antipsychotics. 6. During an interview on 08/20/18 at 12:07 P.M., LPN D said he/she is not familiar with the GDR process. He/She said a pharmacist does come in monthly but he/she is unfamiliar with the process. He/She said the pharmacist fills out a recommendation sheet and give to the DON, nursing gets a copy. He/She said nursing is responsible for implementing medication changes and the physicians are responsible for following up to make sure they are done. He/She said he/she is not sure why there was no physician response for the pharmacist’s recommendation on 11/14/17 for Resident #41. He/She said he/she is not sure why there was no physician response for the pharmacist’s recommendation on 05/25/18 for Resident #27. He/She said if a resident is on an antipsychotic, there should be a diagnosis listed, and if a [DIAGNOSES REDACTED]. He/She is not sure why Resident #67 is on an antipsychotic. During an interview on 8/20/18 at 12:32 P.M., the DON said he/she gets the recommendations from the pharmacist and he/she sends the recommendations to the physician by a fax. The DON said if he/she does not hear back from the physician then he/she calls the physician back and would expect the physician to document if he/she agrees or disagrees and if he/she disagrees then would need a explanation. If the physician does not respond in a couple of days, the DON is expected to follow up until an adequate response is received. The DON said he/she expects the antipsychotic medications to have an appropriate [DIAGNOSES REDACTED]. The DON said all PRN psychoactive medications should have a 14 day stop date. The DON does not know what happened to the recommendation for Resident #27’s [MEDICATION NAME] GDR. | |
| F 0761 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/31/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265530 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER JEFFERSON CITY NURSING AND REHABILITATION CTR, LLC | STREET ADDRESS, CITY, STATE, ZIP 1221 SOUTHGATE LANE | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0761 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility’s licensed staff failed to ensure medications were monitored and stored in a safe and effective manner. Licensed staff failed to remove and discard discontinued medication and improperly labeled medication from the refrigerator in two of three sampled medication room. The facility census was 78. 1. Review of the manufacturers’ recommendations for [MEDICATION NAME] Insulin (a rapid-acting human insulin analog used to lower blood glucose) and for [MEDICATION NAME] shows the medication must be discarded 28 days after the vial has been opened. 2. Observation of the rehabilitation medication cart on 08/14/18 at 02:10 P.M., showed one open, undated bottle of [MEDICATION NAME] insulin. 3. Observation of the 100/300 medication cart on 08/14/18 at 02:34 P.M., showed two [MEDICATION NAME]pens past the 28 day expiration date. The first pen was dated 07/04/18 and the second pen was dated 07/05/18. 4. Observation of the rehabilitation medication room on 08/14/18 at 02:52 P.M., showed an open, undated [MEDICAL CONDITION] vial, and 13 vials of [MEDICAL CONDITION] vaccine with expiration dates of 06/04/18. 5. During an interview on 08/14/18 at 02:30 P.M., Registered Nurse (RN) J said the insulin should always be dated when opened and the end date also written on the medication. The RN said the insulin should be discarded 28 days after opening the medication. The RN said it is every charge nurse’s responsibility to check the medication in the medication cart/refrigerator to make sure it is not outdated. The RN is not sure who is responsible for routinely checking the medication rooms/carts/refrigerators for compliance. During an interview on 08/14/18 at 02:44 P.M., the Director of Nursing (DON) said it is the responsibility of every nurse to monitor for expired medications. The DON said the Consultant Pharmacist comes monthly and reviews the medication room and medication carts for compliance. The DON does not know who is responsible to check the medication rooms/refrigerators/or medication carts for expired medications, but would expect each nurse assigned to the medication pass to monitor for expired medications. It is the charge nurse’s responsibility to follow up to be sure this is done. The DON said he/she expects staff to discard the outdated medications. | |
| F 0880 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | Provide and implement an infection prevention and control program. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1. According to the Infection Control Guidelines for Long Term Care Facilities (Section |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/31/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265530 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER JEFFERSON CITY NURSING AND REHABILITATION CTR, LLC | STREET ADDRESS, CITY, STATE, ZIP 1221 SOUTHGATE LANE | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0880 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 31) 2. Review of the resident’s [MEDICAL CONDITION] care, policy dated updated (MONTH) 2014, showed staff are directed to do the following: -If using disposable inner cannula maintain and continue aseptic technique; -Unlock and discard of disposable inner cannula in appropriate waste receptale; -Clean [MEDICAL CONDITION] and underneath flange removing secreations with gauze soaked with normal saline or 1/2 normal saline/hydrogen peroxide; -Replace inner cannula and lock iinto place; -Change [MEDICAL CONDITION] sterile drain sponge; -Wash hands. 3. Review of Resident #44’s Minimum Data Set (MDS), a federally mandated assessment tool, dated 12/15/17, showed staff assessed the resident as follows: -No cognitive impairment; -Required extensive assistance of one staff for bed mobility, transfer, locomotion on toilet, dressing, eating, personal hygiene, and bathing; -Incontinent of bowel and bladder; -Did not receive [MEDICAL CONDITION] care. Review of the resident’s care plan, dated 3/30/18, showed facility staff were directed to do the following: -#6 shiley [MEDICATION NAME] XL [MEDICAL CONDITION] (type of [MEDICAL CONDITION] cathter); -Monitor changes; -Head of bed up when short of breath; -Administer oxygen as ordered and provide humidifcation; -Change [MEDICAL CONDITION] drain sponge every shift and as needed; -Change cannula every day and as needed; -Has catheter and provide catheter care every shift; -Use collection leg bag when resident is sitting, standing, or walking; -Change indweling cathter and drainge bag based on Center for Disease Control (CDC) guidelines. Review of the resident’s Physician order [REDACTED]. -Clean [MEDICAL CONDITION] site with 3:1 hydrogen peroxide solution, apply clean sponge, change [MEDICAL CONDITION] every three months, last time was changed was on 7/18/18. [MEDICAL CONDITION] size 6 millimeters (mm) inner cannula 6.0 french [MEDICATION NAME] Shiley; -Change indwelling catheter or drainage bag based on cdc guideline. Observation on 8/13/18 at 12:16 P.M., showed the resident in his/her room in his/her wheelchair. Observation showed the resident catheter bag and tubing touched the floor. Observation on 8/13/18 at 2:57 P.M., showed the resident in his/her room in his/her wheelchair. Observation showed the resident catheter bag and tubing touched the floor. Observation on 8/14/18 at 10:08 A.M., showed the resident in his/her room in his/her wheelchair. Observation showed the resident catheter bag and tubing touched the floor. Observation on 8/15/18 at 1:01 P.M., showed the resident in his/her room in his/her wheelchair. Observation showed the resident catheter bag and tubing touched the floor. Observation on 8/15/18 at 8:45 P.M., showed the resident in his/her bed. Observation showed Licensed Practical Nurse (LPN) G entered the room and applied glove. LPN G removed the resident’s [MEDICAL CONDITION] cap and it fell on the floor. LPN G removed the resident’s inner cannula of the [MEDICAL CONDITION] and opened a new inner cannula package. LPN G inserted the resident’s clean inner cannula into the [MEDICAL CONDITION]. LPN G picked up the resident’s [MEDICAL CONDITION] cap off the floor and ran it under water. LPN G placed the cap in a denture storage container, removed his/her gloves and |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/31/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265530 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER JEFFERSON CITY NURSING AND REHABILITATION CTR, LLC | STREET ADDRESS, CITY, STATE, ZIP 1221 SOUTHGATE LANE | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0880 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 32) left the resident’s room. LPN G did not wash his/her hands or change the resident’s inner cannula of the [MEDICAL CONDITION] in a manner to prevent the spread of bacteria, and did not apply the new inner cannula with a sterile technique as directed by policy and commonly accepted infection control practices. Observation on 8/16/18 at 12:29 P.M., showed the resident in his/her room in his/her wheelchair. Observation showed the resident’s catheter bag and tubing touched the floor. During an interview on 8/17/18 at 4:54 P.M., LPN G said staff should wash their hands when they enter/exit a room, between dirty and clean tasks and between glove changes. LPN G said when staff remove the [MEDICAL CONDITION] inner cannula that is a clean procedure and staff should wash their hands, but when staff apply the new inner cannula that is a sterile procedure. LPN G said he/she is not sure why he/she didn’t change his/her gloves or wash hands or do the sterile procedure on 8/15/18. During an interview on 8/20/18 at 12:32 P.M., the Director of Nursing (DON) said he/she is not sure if changing the inner cannula of the [MEDICAL CONDITION] is a sterile procedure or not. The DON said he/she expects staff should wash their hands or change in change gloves when they enter/exit a resident’s room, between dirty clean tasks, and between glove changes. The DON said staff should keep catheter bags and tubing off floor. 4. Observation on 08/15/18 at 01:02 P.M., showed Certified Nursing Assistants (CNA) K provided care for Resident #7. After providing care the CNA removed a pillow case and observed a large blood stain on the pillow. The CNA said it was possibly from the resident’s fall on 08/13/18. The CNA bagged the pillow and pillow case up and took it from the room. During an interview on 08/15/18 at 2:00 P.M., the CNA said any item which has come into contact with blood should be bagged in a biohazard bag and taken to the laundry right away. The CNA would not expect a clean pillow case to be applied to a soiled pillow, and did not know why a pillow case had been reapplied to the soiled pillow. -Observation on 08/13/18 at 02:38 P.M., showed Resident #17’s humidifier was not bubbling and the nasal cannula tubing lay across the concentrator, unbagged and uncovered. The humidifier was not dated and the cannula tubing was dated 07/28/18. Observation on 08/15/18 at 12:46 P.M., showed the resident’s humidifier was not bubbling and the nasal cannula tubing was lying on the floor. Observation showed the oxygen concentrator filter very dirty. The resident complained his/her oxygen was not working. The Director of Nursing (DON) was told the resident complained the oxygen wasn’t working and he/she took the humidifier off and reapplied it. The humidifier began bubbling. Observation showed the DON picked the nasal cannula tubing up off the floor and handed it to the resident. The DON did not disinfect or replace the contaminated tubing before he/she gave it to the resident to use. Observation on 08/16/18 at 03:17 P.M., showed the nasal cannula tubing lay across the bed uncovered, unbagged, and dated 07/28/18. During an interview on 08/15/18 at 01:00 P.M. the DON said the humidifiers, nasal cannulas, and oxygen concentrator filters should be cleaned/changed weekly. The DON also said the nasal cannula tubing should be stored in dated plastic bags. The DON does not know why it is not. | |
