Original Inspection report

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

(X2) MULTIPLE CONSTRUCTION
A. BUILDING___________
B. WING___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

JEFFERSON CITY NURSING AND REHABILITATION CTR, LLC

STREET ADDRESS, CITY, STATE, ZIP

1221 SOUTHGATE LANE
JEFFERSON CITY, MO 65110

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 TAGSUMMARY 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
resident dignity by failing to provide a dignified dining room environment and inclusion
in activities to promote maintenance of quality of life for one resident (Resident #53).
The facility census was 75.
1. Review of the facility’s Dining Room Standards policy, dated (YEAR), showed staff are
directed to ensure an attractive, cheerful dining room is maintained with comfortable
sound, lighting, furnishings, temperature, and adequate space.
2. Review of Resident #53’s Quarterly Minimum Data Sheet (MDS), a federally mandated
assessment tool, dated 07/05/18, showed staff assessed the resident as follows:
-Rarely/Never understood;
-Behaviors not directed towards others during the lookback period;
-Required supervision and set up with eating;
-Weight loss.
Review of the resident’s care plan, dated 07/2018, showed staff are directed to:
-Offer snacks;
-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 his/her lap;
-Allow the resident to eat at his/her own table;
-Serve the resident meals on a plate with a lip or guard;
-Allow the resident ample time to consume food;
-Provide assistance with feeding and cueing as needed;
-Promptly offer the resident food alternatives when appropriate.
Observation on 08/13/18 at 11:44 A.M., showed the resident in his/her broda chair
(specialized reclining wheelchair) alone at a small corner table with a table top size of
16×15 and a height of 23 1/2 (under two feet tall) 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 08/14/18 at 11:36 A.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 08/15/18 at 11:55 A.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 resident’s plate fell off the table onto the floor behind the
table. Staff did not assist the resident after the plate fell on to the floor.
Observation on 08/15/18 at 12:40 P.M., showed the resident in his/her broda chair alone
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 assist the
resident with incontinence care or assist the resident out of the dining room after lunch.
Additional observation showed the resident scooted to the edge of his/her chair, turned
backward, and twisted the chair’s tag with his/her hands. Staff did not engage the
resident in an activity.
Observation on 08/15/18 at 1:55 P.M., showed the resident in his/her broda chair alone

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

(X2) MULTIPLE CONSTRUCTION
A. BUILDING___________
B. WING___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

JEFFERSON CITY NURSING AND REHABILITATION CTR, LLC

STREET ADDRESS, CITY, STATE, ZIP

1221 SOUTHGATE LANE
JEFFERSON CITY, MO 65110

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 TAGSUMMARY 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**
Based on record review and interview, facility staff failed to document a complete 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

(X2) MULTIPLE CONSTRUCTION
A. BUILDING___________
B. WING___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

JEFFERSON CITY NURSING AND REHABILITATION CTR, LLC

STREET ADDRESS, CITY, STATE, ZIP

1221 SOUTHGATE LANE
JEFFERSON CITY, MO 65110

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 TAGSUMMARY 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

(X2) MULTIPLE CONSTRUCTION
A. BUILDING___________
B. WING___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

JEFFERSON CITY NURSING AND REHABILITATION CTR, LLC

STREET ADDRESS, CITY, STATE, ZIP

1221 SOUTHGATE LANE
JEFFERSON CITY, MO 65110

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 TAGSUMMARY 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**
Based on observation, interview, and record review, facility staff failed to develop and
implement measurable goals and interventions for comprehensive care plans for four
residents (Residents #1, #7, #9, #27) related to bed rails, one resident (Resident #53)
related to activities, one resident (Resident #30) related to activities of daily living,
one resident (Resident #47) related to hospitalization s and medication refusals, one
residents (Residents #53) related to nutrition, one resident (Resident #1) related to
respiratory care, and one resident (Resident #67) related to [MEDICAL CONDITION]
medications. The facility census was 75.
1. Review of the facility’s policy, Comprehensive Person Centered Care Plans, dated
(MONTH) (YEAR), showed staff are directed to do the following:
-A comprehensive person centered care plan shall be fully developed within seven days
after completion of the Admission Minimum Data Set (MDS) assessment, a federally mandated
assessment tool;
-The interdisciplinary team along with the resident and/or Resident Representative will
identify resident problems, needs, strengths, life history, preferences, and goals;
-Each problem, need, or strength a resident-centered goal is developed;
-Staff approaches are developed for each problem/need;
-Comprehensive Person Centered Care Plan can be reviewed and/or revised at quarterly
intervals in conjunction with the completion of MDS quarterly, significant change, and
annual assessments per Resident Assessment Instruction (RAI) manual.
2. 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;
-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;
-Catheter;
-Always continent of bowel;

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

(X2) MULTIPLE CONSTRUCTION
A. BUILDING___________
B. WING___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

JEFFERSON CITY NURSING AND REHABILITATION CTR, LLC

STREET ADDRESS, CITY, STATE, ZIP

1221 SOUTHGATE LANE
JEFFERSON CITY, MO 65110

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 TAGSUMMARY 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

(X2) MULTIPLE CONSTRUCTION
A. BUILDING___________
B. WING___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

JEFFERSON CITY NURSING AND REHABILITATION CTR, LLC

STREET ADDRESS, CITY, STATE, ZIP

1221 SOUTHGATE LANE
JEFFERSON CITY, MO 65110

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 TAGSUMMARY 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

(X2) MULTIPLE CONSTRUCTION
A. BUILDING___________
B. WING___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

JEFFERSON CITY NURSING AND REHABILITATION CTR, LLC

STREET ADDRESS, CITY, STATE, ZIP

1221 SOUTHGATE LANE
JEFFERSON CITY, MO 65110

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 TAGSUMMARY 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

(X2) MULTIPLE CONSTRUCTION
A. BUILDING___________
B. WING___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

JEFFERSON CITY NURSING AND REHABILITATION CTR, LLC

STREET ADDRESS, CITY, STATE, ZIP

1221 SOUTHGATE LANE
JEFFERSON CITY, MO 65110

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 TAGSUMMARY 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

(X2) MULTIPLE CONSTRUCTION
A. BUILDING___________
B. WING___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

JEFFERSON CITY NURSING AND REHABILITATION CTR, LLC

STREET ADDRESS, CITY, STATE, ZIP

1221 SOUTHGATE LANE
JEFFERSON CITY, MO 65110

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 TAGSUMMARY 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

(X2) MULTIPLE CONSTRUCTION
A. BUILDING___________
B. WING___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

JEFFERSON CITY NURSING AND REHABILITATION CTR, LLC

STREET ADDRESS, CITY, STATE, ZIP

1221 SOUTHGATE LANE
JEFFERSON CITY, MO 65110

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 TAGSUMMARY 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**
Based on observation, interview, and record review facility staff failed to update the
plan of care with changes in resident’s needs for three residents (Residents #7, #9, and
#30). The facility census was 75.
1. Review of the faccility’s Comprehensive Person Centered Care Plans, dated (MONTH)
(YEAR), showed staff were directed to do the following:
-Comprehensive Person Centered Care Plan can be reviewed and/or revised at quarterly
intervals in conjunction with the completion of MDS quarterly, significant change, and
annual assessments per Resident Assessment Instruction (RAI) mannual;
-Upon a change in condition, the care plan will be updated or an instant care plan will be
initiated if applicable;
-An instant care plan can be completed wth a change in resident condition if there is no
care plan available or until the comprehensive care plan is updated;
-Remove the instant care plan from the medical record when the information is added to the
comprehensive care plan.
2. Review of Resident #7’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;
Review of the resident’s care plan, reviewed 2/2018, showed the care plan does not provide
specific direction for the number of staff required to assist the resident with his/her
activities of daily living (ADLs).
3. Review of Resident’s #9’s MDS, dated [DATE], showed staff assessed the resident as
follows:
-Moderate cognitive impairment;

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

(X2) MULTIPLE CONSTRUCTION
A. BUILDING___________
B. WING___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

JEFFERSON CITY NURSING AND REHABILITATION CTR, LLC

STREET ADDRESS, CITY, STATE, ZIP

1221 SOUTHGATE LANE
JEFFERSON CITY, MO 65110

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 TAGSUMMARY 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

(X2) MULTIPLE CONSTRUCTION
A. BUILDING___________
B. WING___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

JEFFERSON CITY NURSING AND REHABILITATION CTR, LLC

STREET ADDRESS, CITY, STATE, ZIP

1221 SOUTHGATE LANE
JEFFERSON CITY, MO 65110

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 TAGSUMMARY 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
oncoming and offgoing staff member verified and reconciled the narcotic count as accurate
at each shift change. The facility census was 78.
1. Review of the Controlled Substance Tracking Form for 300 hall, dated 06/22/18 –
08/14/18, showed staff failed to sign the narcotic count as follows:
-06/22/18: 11:00 P.M. on-coming 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

(X2) MULTIPLE CONSTRUCTION
A. BUILDING___________
B. WING___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

JEFFERSON CITY NURSING AND REHABILITATION CTR, LLC

STREET ADDRESS, CITY, STATE, ZIP

1221 SOUTHGATE LANE
JEFFERSON CITY, MO 65110

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 TAGSUMMARY 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

(X2) MULTIPLE CONSTRUCTION
A. BUILDING___________
B. WING___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

JEFFERSON CITY NURSING AND REHABILITATION CTR, LLC

STREET ADDRESS, CITY, STATE, ZIP

1221 SOUTHGATE LANE
JEFFERSON CITY, MO 65110

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 TAGSUMMARY 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**
Based on observation, interview, and record review facility staff failed to provide
adequate showers to three residents (Residents #1, #30, and #54). The facility census was
75.
Review showed staff did not provide a policy regarding showers.
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;

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

(X2) MULTIPLE CONSTRUCTION
A. BUILDING___________
B. WING___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

JEFFERSON CITY NURSING AND REHABILITATION CTR, LLC

STREET ADDRESS, CITY, STATE, ZIP

1221 SOUTHGATE LANE
JEFFERSON CITY, MO 65110

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 TAGSUMMARY 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

(X2) MULTIPLE CONSTRUCTION
A. BUILDING___________
B. WING___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

JEFFERSON CITY NURSING AND REHABILITATION CTR, LLC

STREET ADDRESS, CITY, STATE, ZIP

1221 SOUTHGATE LANE
JEFFERSON CITY, MO 65110

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 TAGSUMMARY 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**
Based on observation, interview, and record review, facility staff failed to transcribe

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

(X2) MULTIPLE CONSTRUCTION
A. BUILDING___________
B. WING___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

JEFFERSON CITY NURSING AND REHABILITATION CTR, LLC

STREET ADDRESS, CITY, STATE, ZIP

1221 SOUTHGATE LANE
JEFFERSON CITY, MO 65110

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 TAGSUMMARY 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

(X2) MULTIPLE CONSTRUCTION
A. BUILDING___________
B. WING___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

JEFFERSON CITY NURSING AND REHABILITATION CTR, LLC

STREET ADDRESS, CITY, STATE, ZIP

1221 SOUTHGATE LANE
JEFFERSON CITY, MO 65110

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 TAGSUMMARY 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

(X2) MULTIPLE CONSTRUCTION
A. BUILDING___________
B. WING___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

JEFFERSON CITY NURSING AND REHABILITATION CTR, LLC

STREET ADDRESS, CITY, STATE, ZIP

1221 SOUTHGATE LANE
JEFFERSON CITY, MO 65110

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 TAGSUMMARY 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

(X2) MULTIPLE CONSTRUCTION
A. BUILDING___________
B. WING___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

JEFFERSON CITY NURSING AND REHABILITATION CTR, LLC

STREET ADDRESS, CITY, STATE, ZIP

1221 SOUTHGATE LANE
JEFFERSON CITY, MO 65110

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 TAGSUMMARY 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

(X2) MULTIPLE CONSTRUCTION
A. BUILDING___________
B. WING___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

JEFFERSON CITY NURSING AND REHABILITATION CTR, LLC

STREET ADDRESS, CITY, STATE, ZIP

1221 SOUTHGATE LANE
JEFFERSON CITY, MO 65110

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 TAGSUMMARY 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

(X2) MULTIPLE CONSTRUCTION
A. BUILDING___________
B. WING___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

JEFFERSON CITY NURSING AND REHABILITATION CTR, LLC

STREET ADDRESS, CITY, STATE, ZIP

1221 SOUTHGATE LANE
JEFFERSON CITY, MO 65110

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 TAGSUMMARY 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
reinstructed the resident on trilogy vent, proper procedure for putting on full face mask.
Reinstructed on how to connect tubing or oxygen to unit. Reinstructed on the humidifier –
trilogy vent functioning properly. Further review showed inspection of the [MEDICAL
CONDITION] did not occur until four days after the resident complained of trouble
breathing.
During an interview on 8/20/18 at 12:00 P.M., the Administrator said staff should assess
the resident and notify the physician as soon as staff notice the resident had difficulty
breathing or appears to have respiratory distress. The Administrator said he/she is not
aware that the resident has an order for [REDACTED]. The Administrator said there are no
issues with hoyer weight scales. He/She said that the CNAs had come to him/her to tell her
they don’t work and he/she showed them that the mechanical lift scales do work multiple
times.
During an interview on 8/20/18 at 12:32 P.M., the DON said staff should assess the
resident’s respiratory status every shift including pulse oximeter, listen to his/her lung
sounds, check oxygen saturation, and ensure the oxygen concentrator is working. The DON
said if the resident is having problems breathing they should assess the resident and then
call the physician, but not give an antianxiety medication without doing an assessment of
the resident’s respiratory status. The DON said staff should assess and notify the
physician immediately not 30 minutes later.
During an interview on 08/17/18 at 2:07 P.M., the Nurse Practitioner said he/she would
expect staff to transfer hospital orders over to the resident’s POS and fax them to
his/her office. He/She said daily weights have to be done no matter how difficult it is
because they can make a huge difference for the resident. He/She said the resident has
never refused daily weights and he/she wants them done. He/She said there should be no
reason the facility cannot weigh the resident daily and the order to do daily weights
should not be discontinued. He/She said he/she was unaware the hospital had ordered leg
measurements but he/she would expect the facility to do them daily if instructed by the
hospital. He/She said he/she would expect staff to notify him/her of any weight changes
but he/she has not been notified lately. He/She said he/she expects staff to contact
him/her if the resident is having trouble with his/her [MEDICAL CONDITION] and they should
also contact the [MEDICAL CONDITION] provider to have it looked at. He/She said the
[MEDICAL CONDITION] not working could be a sign of fluid retention from [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

(X2) MULTIPLE CONSTRUCTION
A. BUILDING___________
B. WING___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

JEFFERSON CITY NURSING AND REHABILITATION CTR, LLC

STREET ADDRESS, CITY, STATE, ZIP

1221 SOUTHGATE LANE
JEFFERSON CITY, MO 65110

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 TAGSUMMARY 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**
Based on observation, interview, and record review, facility staff failed to ensure the
resident environment remained free of accident hazards. Staff failed to implement fall
interventions for one resident (Resident #7) with a history of falls. The facility census
was 78.
1. Review of the facility’s Accident and Incident Documentation and Investigation Resident
Incident, reviewed (MONTH) (YEAR), showed accidents and/or incidents involving resident
care will be investigated and documented on the Resident Incident Report entry form in the
Long Term Care (LTC) system. An incident is defined as an occurrence which is not
consistent with the routine operation of the facility or the routine care of a particular
resident. Accidents and incidents will be analyzed for trends or patterns to enable the
facility to enhance preventive measures to reduce the occurrence of incidents. The
licensed nurse shall place the resident on the 24 hour report, document the incident, and
notify the supervisor and the Director of Nursing (DON). The licensed nurse may complete a
nurses’note and update the resident care plan as needed. The nurse’s note could contain
the date and time of the incident, clear objective facts of what occurred, the last time
the resident was seen by staff prior to the incident, an evaluation of the residnt’s
condition at the time of the accident/incident, vital signs, and any other physical
characteristics apparent as a result of the accident/incident, any treatment provided, any
contacts made or attempted with the resident’s physician, family, legal representative or
any other health care professional or person involved with the resident’s care, the
resident’s outcome and anhy information concerning the incident.
Review of Resident #7’s care plan, reviewed 2/2018, showed the resident is at risk for
falls due to impaired mobility and his/her choice not to get out of bed or assist with
activities of daily living (ADLs). Interventions are as follows:
-Keep personal items in reach;
-Staff will use a hoyer lift when transferring for showers;
-Staff will keep the half bedrails up so it gives independence with repositioning in bed;
-Encourage to use the trapeze to reposition and exercise;
-Staff to encourage and allow resident to do as much of ADLs as he/she can and praise
efforts.

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

(X2) MULTIPLE CONSTRUCTION
A. BUILDING___________
B. WING___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

JEFFERSON CITY NURSING AND REHABILITATION CTR, LLC

STREET ADDRESS, CITY, STATE, ZIP

1221 SOUTHGATE LANE
JEFFERSON CITY, MO 65110

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 TAGSUMMARY 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

(X2) MULTIPLE CONSTRUCTION
A. BUILDING___________
B. WING___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

JEFFERSON CITY NURSING AND REHABILITATION CTR, LLC

STREET ADDRESS, CITY, STATE, ZIP

1221 SOUTHGATE LANE
JEFFERSON CITY, MO 65110

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 TAGSUMMARY 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**
Based on observation, interview, and record review facility staff failed to complete
required assessments and maintain proper documentation for use of side rails for four
residents (Residents #1, #9, #17, #58). The facility census was 75.
1. Review of the facility’s Clinical Guidance for the Assessment and Implementation of Bed
Rails in Hospitals, Long Term Care Facilities, and Home Care Settings, dated 04/2003,
showed bed rails are defined as adjustable metal or rigid plastic bars that attach to the
bed. They are available in a variety of types, shapes, and sizes ranging from full to
one-half, one-quarter, or one-eighth lengths. Staff are directed to:
-assess the individual resident’s sleeping habits, medical needs, comfort, and freedom of
movement;
-only use bedrails for assessed medical needs;
-create an accompanying care plan designed for the treatment of [REDACTED].
-create a safe bed environment by inspecting, evaluating, maintaining, and upgrading
equipment;
-re-assess the resident needs.
2. 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;
-no mood;
-no 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;
-regular diet;
-no pressure;
-anti depressant 7 days per week;
-oxygen;
– Bilevel Positive Airway Pressure ([MEDICAL CONDITION], a non-invasive form of therapy
for patients suffering from sleep apnea) machine;
-no restraints or alarms.
Review of the resident’s physician’s orders [REDACTED].

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

(X2) MULTIPLE CONSTRUCTION
A. BUILDING___________
B. WING___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

JEFFERSON CITY NURSING AND REHABILITATION CTR, LLC

STREET ADDRESS, CITY, STATE, ZIP

1221 SOUTHGATE LANE
JEFFERSON CITY, MO 65110

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 TAGSUMMARY 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

(X2) MULTIPLE CONSTRUCTION
A. BUILDING___________
B. WING___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

JEFFERSON CITY NURSING AND REHABILITATION CTR, LLC

STREET ADDRESS, CITY, STATE, ZIP

1221 SOUTHGATE LANE
JEFFERSON CITY, MO 65110

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 TAGSUMMARY 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

(X2) MULTIPLE CONSTRUCTION
A. BUILDING___________
B. WING___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

JEFFERSON CITY NURSING AND REHABILITATION CTR, LLC

STREET ADDRESS, CITY, STATE, ZIP

1221 SOUTHGATE LANE
JEFFERSON CITY, MO 65110

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 TAGSUMMARY 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
[DIAGNOSES REDACTED].#67). Additionally facility staff failed to follow through on
pharmacist recommendation for Gradual Dose Reduction (GDR) for three residents (Resident
#27, #35, and #41). The facility census was 75.
1. Review of the facility’s Consultant Pharmacist Services Policy, dated 08/2017, showed
staff are directed to:
-Conduct medication regimen reviews monthly;
-Review medication storage rooms and carts monthly;
-Periodically review emergency drug storage;
-Communicate any identified problems to the physician;
-review Medication Administration Reports (MARs) and physician’s orders [REDACTED].
-assess nursing staff during medication pass;
-assist in reconciliation and destruction of unused controlled medications;
-advise facility on policies and procedures for safe delivery, organization, and
destruction of medications;
-facilitate the resolution of issues with contracted and non-contracted pharmacies;
-conducts in-service education to nursing staff on drug and pharmacy services.
2. Review of Resident #27’s admission Minimum Data Set (MDS), a federally mandated
assessment tool completed by facility staff, dated 05/19/18, showed staff assessed the
resident as follows:
-Cognitively impaired with no behaviors;
-Requires extensive physical assistance of one person for bathing;
-Requires limited physical assistance of one person for dressing, toileting, and personal
hygiene;
-Requires set-up assistance only for bed mobility, transfers, locomotion, and eating;
-Frequently incontinent of bowel and bladder;
-Diagnoses of hypertension, gastric [MEDICAL CONDITION] reflux disease, [MEDICAL
CONDITIONS], dementia, depression;
-Medication use during the seven day look back period include seven days of antipsychotic,
seven days of antidepressant, and seven days of anticoagulant medications.
Review of the resident’s current physician’s orders [REDACTED].
Review of the resident’s MAR, showed staff administered as needed (PRN) [MEDICATION NAME]
on 5/30/18 and twice on 6/17/18.
Review of the resident’s Pharmacist Medication Regimen Review, showed the pharmacist
addressed the PRN [MEDICATION NAME] on the Consultant Pharmacist Medication Regimen Review
Log on 06/20/18 and again on 07/12/18. On 06/20/18, the consultation form shows a letter
was given to the Registered Nurse (RN), however the facility staff were not able to find
the pharmacist’s recommendation letter.
3. Review of resident #35’s Quarterly MDS, dated [DATE], showed staff assessed the
resident as follows:

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

(X2) MULTIPLE CONSTRUCTION
A. BUILDING___________
B. WING___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

JEFFERSON CITY NURSING AND REHABILITATION CTR, LLC

STREET ADDRESS, CITY, STATE, ZIP

1221 SOUTHGATE LANE
JEFFERSON CITY, MO 65110

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 TAGSUMMARY 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

(X2) MULTIPLE CONSTRUCTION
A. BUILDING___________
B. WING___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

JEFFERSON CITY NURSING AND REHABILITATION CTR, LLC

STREET ADDRESS, CITY, STATE, ZIP

1221 SOUTHGATE LANE
JEFFERSON CITY, MO 65110

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 TAGSUMMARY 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

(X2) MULTIPLE CONSTRUCTION
A. BUILDING___________
B. WING___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

JEFFERSON CITY NURSING AND REHABILITATION CTR, LLC

STREET ADDRESS, CITY, STATE, ZIP

1221 SOUTHGATE LANE
JEFFERSON CITY, MO 65110

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 TAGSUMMARY 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**
Based on observation, interview, and record review, facility staff failed to appropriately
wash hands and change gloves and maintain a sterile field during [MEDICAL CONDITION] (a
tube inserted into the neck to maintain an airway and to help breathe) inner cannula
change for one resident (Resident #44). Facility staff failed to keep one residnets
catheter tubing and drainage bag off the floor (Resident #44). The facility census was 75.

1. According to the Infection Control Guidelines for Long Term Care Facilities (Section
3.0 Body Substance Precautions): *Dirty gloves are worse than dirty hands because
micro-organisms adhere to the surface of a glove easier than to the skin of your hands.
*Hand washing remains the single most effective means of preventing disease transmission;
wash hands whenever they are soiled with body substance and when each resident’s care is
completed.

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

(X2) MULTIPLE CONSTRUCTION
A. BUILDING___________
B. WING___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

JEFFERSON CITY NURSING AND REHABILITATION CTR, LLC

STREET ADDRESS, CITY, STATE, ZIP

1221 SOUTHGATE LANE
JEFFERSON CITY, MO 65110

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 TAGSUMMARY 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

(X2) MULTIPLE CONSTRUCTION
A. BUILDING___________
B. WING___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

JEFFERSON CITY NURSING AND REHABILITATION CTR, LLC

STREET ADDRESS, CITY, STATE, ZIP

1221 SOUTHGATE LANE
JEFFERSON CITY, MO 65110

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 TAGSUMMARY 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.