Jefferson City Health and Rehab Center

In the surveyor’s words

From the most serious findings on record at Jefferson City Health and Rehab Center, in the surveyor’s own words.

• Actual harm, isolatedF760Jun 10, 2025

  Based on review of facility policies, medical record review, manufacturer recommendations for administration of morphine extended release capsules and tablets, the facility's investigation, including witness statements, emergency medical services (EMS) records, police reports, hospital records and interviews, the facility failed to prevent significant medication errors for 1 resident (Resident #6) of 13 sampled residents. The facility failure occurred on 5/2/2024 when a staff nurse, Licensed Practical Nurse (LPN B) administered the wrong medications to the wrong patient, which included long-acting Morphine Sulfate (a potent opioid narcotic) 30 milligrams (mg) dose, extended release formula, Trazadone (an antidepressant) 200 mg dose, and Ativan 1 mg dose (a benzodiazepine, anxiolytic… […]

• No harm, potential for more than minimal, widespreadF812Nov 2, 2023

  Based on facility policy review, observations, and interview the facility failed to maintain a sanitary kitchen environment as evidenced by undated, unsealed food observed in 1 of 1 walk-in freezer and failed to ensure expired foods had been discarded in 1 of 1 dry storage areas, which had the potential to affect 142 of 142 residents. The findings include: Review of the facility's policy titled, Food Receiving and Storage, dated [DATE], showed .Foods shall be received and stored in a manner that complies with safe food handling practices .Foods stored in the refrigerator or freezer will be covered, labeled and dated . […]

• No harm, potential for more than minimal, isolatedF641Nov 2, 2023

  Based on medical record review and interview, the facility failed to develop an accurate Minimum Data Set (MDS) assessment for 1 resident (Resident #132) related to discharge location, for communication needs related to interpreter services for 1 resident (Resident #92), and medication use for 1 resident (Resident #118) of 28 residents reviewed for MDS assessments. The findings include: Resident #132 was admitted to the facility on [DATE] with diagnoses including Congestive Heart Failure, Diabetes, Hypertension, and Chronic Respiratory Failure. Review of a Nurse Progress Note dated 9/8/2023, showed Resident #132 .discharged instructions discussed with resident and son .Resident and son signed discharge instructions with copy given to resident son. […]

• No harm, potential for more than minimal, isolatedF645Nov 2, 2023

  Based on facility policy review, medical record review, and interview, the facility failed to ensure a Pre-Admission Screening and Resident Review (PASARR) screen was accurate after mental health diagnoses was identified for 1 resident (Resident #110) of 11 residents reviewed for PASARR. The findings include: Review of the facility's policy titled, PASARR- Pre-Admission Screen and Resident Review, dated 10/30/2023, showed, .facility must coordinate with pre-admission screening and resident review program .All residents are required to have a level I PASRR [PASSAR]screen prior to or upon admission . Resident #110 was admitted to the facility on [DATE] with diagnoses including Depression and Psychosis. […]

• No harm, potential for more than minimal, isolatedF657Nov 2, 2023

  Based on facility policy review, medical record review, and interview the facility failed to revise the care plan related to fall interventions for 2 residents (Resident #87 and Resident #116) of 28 care plans reviewed. The findings include: Review of the facility policy titled, Comprehensive Care Plans, revised 6/30/2022, showed .It is the policy of this facility to develop and implement a comprehensive .care plan for each resident .The comprehensive care plan will be .revised by the interdisciplinary team . Review of the facility policy titled, Falls-Clinical Protocol, revised 10/26/2023, showed .Interventions should be .implemented per the assessed needs .Update the plan of care with the new or revised interventions . […]