Every finding on record at Life Care Center of Jefferson City

Based on review of the facility policy, review of kitchen equipment cleaning documentation, observation, and interview, the facility failed to ensure kitchen equipment was maintained in a clean and sanitary condition. The findings include: Review of the facility's policy titled, Sanitation and Maintenance, dated 4/26/2023, revealed .cleaning fixed equipment .cleaned with detergent and hot water, rinsed, air-dried, and sprayed with a sanitizing solution . During an observation of the kitchen with the Dietary Manager (DM) and Registered Dietitian (RD) on 6/16/2025 from 11:05 AM-11:55 AM, revealed the following: - The 6-burner gas stove had dried dark brown food debris present on the handles to the oven compartments. - The steamer had light brown food debris present on the bottom front of the door and the operational control panel of the unit. - The deep fryer had copious amounts of granular food debris present on the top drip tray of the unit. The sides of the deep fryer had food debris granules present with a dried tan fluid streaked on both sides of the unit. - An electrical box mounted to a pillar beside the deep fryer was observed with the dirty and debris and was sticky to the touch. During an interview on 6/16/2025 at 11:55 AM, the RD stated the kitchen was to be cleaned daily and deep cleaned each week. The RD acknowledged the food debris and build up on the kitchen equipment and confirmed the kitchen equipment was not maintained in a clean and sanitary condition.

Based on facility policy review, manufacturer guidelines review, observation, and interview, the facility failed to discard an expired multi-dose vial of Tuberculin (TB) purified protein derivative (ppd) (an injectable medication used to detect the bacteria that causes Mycobacterium tuberculosis) and failed to date an opened multi-dose vial of TB ppd stored in 1 of 2 medication refrigerators observed. The findings include: Review of the facility policy titled, Storage and Expiration Dating of Medications and Biologicals, dated [DATE], revealed .Once any medication or biological package is opened, facility should follow manufacturer/supplier guidelines with respect to expiration dates for opened medications. Facility staff should record the date opened on the primary medication container .vial, bottle .If a multi-dose vial of an injectable medication has been opened or accessed .needle-punctured .the vial should be dated and discarded within 28 days unless the manufacturer specifies a different (shorter or longer) date for that opened vial . Review of manufacturer guidelines titled, APLISOL - tubercullin purified protein derivative [TB ppd] injection, dated 8/2024, revealed .Storage .This product should be stored between .36* [degrees] and 46* F [degrees Fahrenheit] .Vials in use more than 30 days should be discarded due to possible oxidation and degradation which may affect potency . During an observation of the Unit 2 Medication Storage Room and interview with Registered Nurse (RN) A on [DATE] at 8:10 AM, revealed in the medication refrigerator, 1 of the 30 milliliter (ml) multi-dose vials of TB ppd was 1/4 full with an opened date of 5/6, with no year noted. RN A stated the vial of TB ppd was opened on [DATE], was not discarded after 30 days of opening, and was available for resident use. Continued observation revealed a 2nd 30 ml opened multi-dose vial of TB ppd was 3/4 full and did not contain a date the vial had been opened. RN A confirmed the opened vial of TB ppd did not contain an opened date, was unable to provide a date the vial was opened, and was available for resident use. During an interview on [DATE] at 12:05 PM, the Director of Nursing (DON) stated the 30 ml vial of TB ppd dated 5/6 was not discarded after 30 days of opening and the 2nd 30 ml vial of TB ppd did not include a date the vial had been opened. The DON confirmed the 2 vials of TB ppd which was stored in the Unit 2 medication refrigerator, was available for resident use, and should have been discarded.

Based on review of the Centers for Medicare and Medicaid (CMS) Resident Assessment Instrument (RAI) Version 3.0 Manual, medical record review, and interview, the facility failed to accurately complete a Minimum Data Set (MDS) assessment for 2 Residents (Resident #50 and #75) of 9 residents reviewed for anticoagulant use. The findings include: Review of the facility's policy titled, Certification of Accuracy of the MDS, revised 4/22/2025, revealed .each person completing a portion of the MDS is required to sign attestation certifying they have used the Centers for Medicare and Medicaid Long-Term Care Facility Resident Assessment Instrument User's Manual to complete the MDS .Definition-Accuracy of Assessment-means that the appropriate health professionals correctly document the resident's medical, functional, and psychosocial problems .using the appropriate Resident Assessment Instrument (RAI) . Review of the RAI Version 3.0 Manual, Chapter 3, dated 10/2024, revealed instructions .High-Risk Drug Classes: Use and Indication (cont.) .Do not code antiplatelet medications such as aspirin/extended release, dipyridamole [antiplatelet-helps with clotting of blood], or clopidogrel [antiplatelet] as [anticoagulant] [blood thinner] . Review of the medical record revealed Resident #50 was admitted to the facility on [DATE] with diagnoses including Cerebral Palsy, Epilepsy, Congestive Heart Failure, Muscle Weakness, and Diabetes Mellitus. Review of the Physician's Orders dated 4/1/2025, revealed Resident #50 had an active Physician's Order for .Aspirin EC [enteric coated] Tablet Delayed Release 81 MG [milligram] PO [by mouth] one time a day . and .clopidogrel F/C [film coated] 75 mg tablet PO one time a day . There were no orders documented for anticoagulant medication. Review of an admission MDS assessment dated [DATE], revealed Resident #50 was coded on the MDS as being on an anticoagulant medication. Review of the medical record revealed Resident #75 was admitted to the facility on [DATE] with diagnoses including Displaced Intertrochanteric Fracture of Left Femur, Other Abnormalities of Gait and Mobility, and Acute Cystitis with Hematuria. Review of the Physician's Orders dated 4/11/2025, revealed Resident #75 had an active Physician's Order for .Aspirin EC Tablet Delayed Release 325 MG PO one time a day . There were no orders documented for anticoagulant medication. Review of an admission MDS assessment dated [DATE], revealed Resident #75 was coded on the MDS as being on an anticoagulant medication. During an interview on 6/18/2025 at 8:45 AM, the MDS Coordinator confirmed the MDS assessments for Residents #46 and #75 were inaccurately marked for use of anticoagulant medication, in contradiction to the RAI manual's definition of anticoagulant medication.

Based on facility policy review, medical record review, observation and interview, the facility failed to ensure oxygen therapy was administered as ordered for 1 Resident (Resident #50) of 6 residents reviewed for oxygen therapy. The findings include: Review of the facility's policy titled, Oxygen Administration (Infection Control, Safety, & Storage), revised 10/11/2024, revealed .the facility must ensure that a resident who needs respiratory care .is provided such care, consistent with professional standards of practice . Review of the medical record revealed Resident #50 was admitted to the facility on [DATE] with diagnoses including Cerebral Palsy, Epilepsy, Congestive Heart Failure, Muscle Weakness, and Diabetes Mellitus. Review of the Comprehensive Care Plan dated 3/28/2025, revealed Resident #50's Care Plan included .the resident has oxygen therapy r/t [related to] CHF [Congestive Heart Failure] .The resident will have no s/sx [signs/symptoms] of poor oxygen absorption .oxygen settings: O2 [oxygen] via [by] nasal prongs @ [at] 3L [liters] continuously .observe for s/sx of respiratory distress and report to MD [medical doctor] PRN [as needed]: Respirations, Pulse oximetry . Review of the Physician's Order for Resident #50 dated 3/31/2025, revealed .oxygen at 3 liters/minute continuously per nasal canula . Review of the admission Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #50 scored an 8 on the Brief Interview for Mental Status (BIMS) assessment which indicated moderate cognitive impairment. Further review revealed Resident #50 had shortness of breath during exertion, shortness of breath while lying flat, and oxygen in use while in the facility. Review of the Medication Administration Record (MAR) for Resident #50 dated 6/1/2025-6/17/2025 revealed, .oxygen at 3 liters/minute [l/m] continuously per nasal cannula . The MAR was signed by nursing staff for each shift on 6/16/2025 and 6/17/2025, which indicated the physician's order for the oxygen therapy was administered as ordered. During an observation on 6/16/2025 at 12:15 PM, revealed Resident #50 was in the dining room with a nasal cannula in use via portable oxygen cannister which was set at 2 l/m. During an observation on 6/17/2025 at 9:40 AM, revealed Resident #50 was in his room with a nasal cannula in use via oxygen concentrator which was set at 2 l/m. During an observation and interview with Licensed Practical Nurse (LPN) E on 6/17/2025 at 9:45 AM, in Resident #50's room, LPN E confirmed Resident #50's oxygen was set to deliver at 2 l/m and Resident #50 received oxygen at 2 l/m. LPN E confirmed Resident #50's oxygen order was for 3 l/m and the 2 l/m was incorrect. During an interview on 6/18/2025 at 8:00 AM, the Director of Nursing (DON) confirmed oxygen was expected to be administered as ordered by the physician or practitioner.

Based on facility policy review, medical record review, observation, and interview, the facility failed to provide appropriate treatment to restore continence of bowel and bladder for 1 resident (Resident #50) of 4 residents reviewed for bowel and bladder. The findings include: Review of the facility's policy titled, Urinary Incontinence Management, reviewed 9/10/2024, revealed .each resident who is incontinent of urine is identified, assessed and provided appropriate treatment and services to achieve or maintain as much normal bladder function as possible .Procedure: This facility will utilize the [NAME] [renowned medical and nursing journal] procedures . Review of the facility's policy titled, Bowel and Bladder Program, dated 9/24/2024, revealed .the facility will ensure that a resident who is admitted with incontinence of bladder receives appropriate treatment and services .to restore as much normal bladder function as possible .Procedure: This facility will utilize the Lippincott procedures . Review of the medical record revealed Resident #50 was admitted to the facility on [DATE] with diagnoses including Cerebral Palsy, Epilepsy, Congestive Heart Failure, Muscle Weakness, and Diabetes Mellitus. Review of the Comprehensive Care Plan dated 3/28/2025, revealed Resident #50's Care Plan included the focus .bowel incontinence ., with goal .Resident will have no skin breakdown r/t [related to] bowel incontinence ., and interventions including .Assist with toileting as needed .Peri [perineal]care as needed .Remind resident to call for assistance with toileting as soon as need arises . Further review revealed focus .Urinary Incontinence ., with goal .Will have no skin breakdown r/t urinary incontinence ., and interventions including .Assist with toileting as needed .Peri care as needed .Remind resident to call for assistance with toileting as soon as need arises . Review of the admission Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #50 scored an 8 on the Brief Interview for Mental Status (BIMS) assessment which indicated moderate cognitive impairment. Further review revealed Resident #50 was always incontinent of bowel and bladder with no toileting program, and dependent on staff and a mechanical lift for transfers. Review of the medical record document titled, NRSG [Nursing]: Evaluation for Bowel and Bladder Training, dated 3/28/2025, revealed Resident #50 scored a 12 on the evaluation which indicated the resident was a candidate for toileting, timed, or scheduled voiding, and to proceed to the Urinary Incontinence Tool. Continued review revealed the document titled, NRSG: Urinary Incontinence Tool dated 3/28/2025, revealed Resident #50 has .stress incontinence, can comprehend and follow instructions, can recognize urinary urge sensation, can learn to control the urge to void, can contract pelvic floor muscles (Kegels) . and document revealed no comments for referral or additional comments. Review of the medical record document titled, NRSG: Evaluation for Bowel and Bladder Training V2, dated 4/1/2025, revealed Resident #50 scored a 13 which indicated the resident was a candidate for toileting, timed, or scheduled voiding, and to proceed to Urinary Incontinence Tool. Continued review revealed the document titled, NRSG: Urinary Incontinence Tool dated 3/28/2025, revealed Resident #50 has .stress incontinence, can comprehend and follow instructions, can recognize urinary urge sensation, can learn to control the urge to void ., and document revealed no comments for referral or additional comments. Review of the medical record document titled, B&B - Bowel and Bladder Elimination ., for the 30 day look-back period dated 5/19/2025 to 6/17/2025, revealed Resident #50 was incontinent of urine and bowel on 100% of documentation reviewed. During an interview on 6/17/2025 at 2:06 PM, Licensed Practical Nurse (LPN) E, confirmed Resident #50 was incontinent of bowel and bladder, and no toileting, timed, or scheduled voiding had been placed to her knowledge. During an interview on 6/17/2025 at 2:10 PM, Certified Nurse Assistant (CNA) F confirmed Resident #50 was incontinent of bowel and bladder. During an interview on 6/18/2025 at 12:15 PM, the Director of Nursing (DON) confirmed Resident #50 was a candidate for a toileting, timed, or scheduled voiding schedule, and confirmed the Urinary Incontinence Tool indicated Resident #50 should have been placed on a toileting program.

Based on facility policy review, observation and interview, the facility failed to provide a clean and sanitary environment to ensure cleanliness of a stand-up personal fan for 1 resident (Resident #46) of 89 residents reviewed for a clean and sanitary environment. The findings include: Review of the facility's policy titled, Daily Room Cleaning, reviewed 5/16/2025, revealed .The cleanliness of each resident's room is maintained on a daily basis by the housekeeping staff to provide a fresh, clean, and sanitary environment and reduce the potential for nosocomial infections . Review of the medical record revealed Resident #46 was admitted to the facility on [DATE] with diagnoses including Parkinson's Disease, Diabetes Mellitus, Acquired Absence of Left Leg Above Knee, and Peripheral Vascular Disease. During observations on 6/16/2025 at 3:03 PM and on 6/17/2025 at 3:15 PM, Resident #46's room revealed a portable stand-up fan between resident's bed and window area. The fan blades had a large amount of gray dust and thick debris resembling clumped gray fibers which had accumulated on the protective grille. During an observation and interview on 6/17/2025 at 3:30 PM, the Assistant Director of Nursing (ADON) confirmed Resident #46's fan had a large amount of gray dust on the blades and thick debris resembling clumped gray fibers accumulated on the protective grille, and confirmed the debris should not be present with routine cleaning. During an interview on 6/18/2025 at 11:50 AM, the Environmental Service Director confirmed housekeeping was responsible for ensuring the rooms and contents were cleaned routinely.

Based on facility policy review, observation, and interview the facility failed to maintain sanitary kitchen equipment which had the potential to effect 97 residents in the facility. The findings include: Review of the facility policy titled, Sanitation and Maintenance revised 4/26/2023, showed .when cleaning fixed equipment .the non-removable parts .cleaned with detergent and hot water, rinsed and air dried .Procedures for cleaning equipment are readily available .All equipment is .cleaned and sanitized according to manufacturer's instructions .Fixed .equipment in the foodservice area will be .sanitary .Physical facilities are cleaned as often as necessary to keep them clean . During the initial kitchen observation on 3/24/2024 at 10:10 AM, with the Food Service Manager (FSM) showed the outside of the left dishwasher door was 1/3 covered with a dried light brown film from the bottom of door up to the handle. The burners of the gas stove were observed to have dried brown/black food debris present on all; the stove's drip pans had multiple blackened pieces of pasta and other food debris present. The stoves' griddle was observed to be in an unsanitary condition with layer of dried brown/black food debris noted on the right-side of the metal splashguard between the griddle and gas stove. The Left side of the metal splashguard was observed to have been covered with yellowish-brown, sticky substance which also had brown specks of food debris which resembled breading. The double convection oven was observed to have dried brown food debris splatter on the exterior surface of the door handles and atop of both doors of the bottom convection oven. Further observation showed the can opener blade had a dried, thick layer of an unknown brown substance; no shards of metal were present on the blade. The flour and powdered sugar bins were noted to have multiple specks of various colored food debris present on the tops of both bins, and the powdered sugar had a scoop present inside of the bin. Review of the facility's menu for the month of March 2024 showed on week 4-day 6 (Friday) of the menu plan, pasta had been served. Review of the weekly cleaning schedule dated 3/17/2024, showed the dish machine, stove top and grill, deep fryer, and oven/doors were initialed as completed. During an interview on 3/24/2024 at 11:12 AM, the FSM stated it was her expectation the kitchen equipment was cleaned daily and deep cleaned weekly. The FSM confirmed the kitchen equipment was in an unsanitary condition.

Based on facility policy review, medical record review, observations, and interviews, the facility failed to ensure a nasal cannula was stored in a sanitary manner for 1 resident (Resident #78) of 10 residents observed for oxygen use and the facility failed to follow infection control practices for 1 resident (Resident #59) of 4 residents reviewed for medication administration. The findings include: Review of the facility's policy titled, Administration of Medications, dated 8/24/2023, showed .the facility will ensure medications are administered safely and appropriately . Review of the facility policy titled Oxygen Administration (Safety, Storage, Maintenance), dated 2/27/2024, showed .Store oxygen and respiratory supplies in a bag labeled with resident's name when not in use . Resident #78 was admitted to the facility on [DATE], with diagnoses including Aftercare for Joint Replacement and Chronic Obstructive Pulmonary Disease (COPD). Review of the medical record, showed Resident #78 did not have any recent respiratory infections. Resident #78's physician orders dated 3/14/2024, showed an order for continuous oxygen at 2 liters per minute per nasal cannula. During an observation on 3/25/2024 at 10:09 AM, showed an oxygen nasal cannula lying on the floor under Resident #78's bed. Resident #78 was not in the room at the time. The nasal cannula tubing was attached to an oxygen concentrator. There was a plastic storage bag on the oxygen concentrator labeled 3/21 (3/21/2024). During an observation on 3/25/2024 at 2:36 PM, Resident #78 was seated in a wheelchair with a nasal cannula in her nose. The nasal cannula tubing was attached to the oxygen concentrator behind the resident. A plastic storage bag was attached to the oxygen concentrator. A portable oxygen tank on a cart with a tubing curled up and attached was also in the room. During an interview on 3/25/2024 at 2:40 PM, Licensed Practical Nurse (LPN) #1 stated if an oxygen nasal cannula was on the floor, it was not supposed to be used again. The nasal cannula would need to be replaced. LPN #1 stated she had not changed the nasal cannula for Resident #78 that day. LPN #1 also stated if a nasal cannula was removed from the resident it was to be rolled up and placed in a plastic storage bag attached to the oxygen concentrator or portable tank. During an interview on 3/25/2024 at 2:43 PM, the Physical Therapist Assistant (PTA) stated when she transported Resident #78 to her room, she observed the nasal cannula attached to the oxygen concentrator lying on the bed. The PTA stated she removed the nasal cannula attached to the portable oxygen tank and replaced it with the nasal cannula lying on the bed. During an interview on 3/26/2024 at 1:49 PM, the Director of Nursing (DON) confirmed the nasal cannula should have been replaced after it was observed on the floor and not placed back on the resident. Resident #59 was admitted to the facility on [DATE] with diagnoses including Atrial Fibrillation, Major Depressive Disorder, and Chronic Pain Syndrome. Review of the physician recapitulation orders dated 3/2024, showed Resident #59 had ordered Citalopram (anti-depressant) 20mg (milligrams) once a day, Buspirone (anti-anxiety) 10mg three times a day, Apixaban (anti-coagulant) 5mg two times a day, and Hydrocodone-Acetaminophen (pain reliever) 5/325mg every six hours. During a medication administration observation and interview on 3/25/2024 at 8:31 AM, showed LPN #1 had pushed 3 medication (Citalopram, Buspirone, Apixaban) tablets through the blister packets onto her bare hands, placed the tablets into the medication cup. LPN #1 had obtained Hydrocodone (pain reliever) from the narcotic box, pushed one tablet through the blister packet and the pill fell on to the surface of the medication cart. LPN #1 picked up the medication (Hydrocodone) with her bare hands and placed the medication into the medication cup. Further observation showed LPN #1 administered prepared medications to Resident #59. LPN #1 stated she knew she was not supposed to administer medications that way [using her bare hands] but it was easier to use her bare hands to place the medications into the cup. LPN #1 confirmed infection control practices had not been followed during the medication administration for Resident #59.

Based on facility policy review, medical record review, observation, and interviews, the facility failed to ensure tube feeding formula was appropriately labeled for 1 resident (Resident #43) of 1 resident sampled for tube feeding. The findings include: Review of the undated [fiber-fortified tube feeding formula] manufacturers' guidelines, showed .hang no longer than 24 hours . Resident #43 was admitted to the facility on [DATE] with diagnoses including Protein-Calorie Malnutrition, Gastrostomy (tube that is placed directly into the stomach through an abdominal wall incision for administration of food, fluids, and medications), and Dysphasia (difficulty swallowing). Review of an admission Minimum Data Set (MDS) assessment dated [DATE], showed Resident #43 had moderate cognitive impairment, had a feeding tube, and received 51% or more calories through tube feeding. Review of a physician order dated 3/14/2024, showed .Enteral Feed .off at 5 am, on at 9 am [fiber-fortified tube feeding formula] at 60 ml/hr [milliliters/hour] .via pump . Review of Resident #43's care plan revised 3/18/2024, showed .resident requires tube feeding .dependent with tube feeding . Review of Resident #43's Medication Administration Record (MAR) dated 3/2024, showed Licensed Practical Nurse (LPN) #3 had signed the enteral tube feeding formula and had been initiated on 3/24/2024 (no defined time). During an observation on 3/24/2024 at 11:10 AM, showed the enteral tube feeding formula was infusing via pump and had not been labeled with the date or the time. During an interview on 3/24/2024 at 11:15 AM, Resident #43 stated the tube feeding had been initiated that morning (time unknown). During an interview on 3/24/2024 at 11:30 AM, LPN #3 stated the tube feeding formula for Resident #43 was initiated that morning (3/24/2024) and verified the tube feeding formula had not been appropriately labeled with the date or the time. LPN #3 did not know the specific time the tube feeding formula was initiated. During an interview on 3/26/2024 at 3:30 PM, Director of Nursing (DON) stated it was her expectation when an enteral tube feeding is initiated, the enteral formula bottle will be labeled with date and time. DON confirmed the LPN did not label the tube feeding formula with date and time.

Based on facility policy review, record review, observation, and interview, the facility failed to create person-centered care plans for 2 residents (Resident #23 and #25) of 26 residents reviewed for care plans. The finding include: Review of the facility's policy titled Comprehensive Care Plans and Revisions, dated 8/22/2023, showed .the facility will ensure the timeliness of each resident's person-centered, comprehensive care plan, and to ensure that the comprehensive care plan is reviewed and revised by an interdisciplinary team .facility should monitor the resident over time to help identify changes in the resident condition that may warrant and update to the person-centered plan of care . Resident #23 was admitted to the facility on [DATE], with diagnoses including Heart Failure, Respiratory Failure, Alzheimer's Disease, and Obstructive Sleep Apnea. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], showed Resident #23 was cognitively intact. Review of Resident #23's care plan dated 2/2/2024, showed there was no intervention related to the resident's preference to wear the nasal cannula in her mouth. During an observation and interview on 3/24/2024 at 11:55 AM, Resident #23 was observed lying in her bed with the oxygen nasal cannula in her mouth. The tubing was attached to the oxygen concentrator. Resident #23 stated she liked having it in her mouth better than her nose. During observation and interview on 3/25/2024 at 2:55 PM, Resident #23 was observed sitting on the side of the bed with the nasal cannula in her mouth. The resident stated she liked it better that way. During an interview on 3/25/2024 at 3:00 PM, Licensed Practical Nurse (LPN) #1 stated Resident #23 wore the nasal cannula in her mouth. LPN #1 also stated the facility staff had educated Resident #23 on how to wear the nasal cannula, but the resident did not comply. During an interview on 3/26/2024 at 1:49 PM, the Director of Nursing (DON) stated she did not know Resident #23 preferred to wear her nasal cannula in her mouth. The DON confirmed if it was the resident's preference it should have been on the care plan. Resident #25 admitted to the facility on [DATE] with diagnoses including Acute Respiratory Failure, Bipolar Disorder, Anxiety Disorder, and Muscle Weakness. Review of the medical record showed Resident #25 did not have a diagnosis of Dementia. Review of a quarterly MDS assessment dated [DATE], showed Resident #25 was cognitively intact. Review of Resident #25's care plan dated 2/22/2024, showed behavior problem .interventions: Match your body language to your words - frown and shake your head. People with dementia are better at reading non-verbal cues. Don't accidently encourage inappropriate behavior by sending mixed signals . During an interview on 3/26/2024 at 10:15 AM, the Licensed Social Worker (LSW) stated she was responsible for developing Resident #25's care plan. The LSW confirmed Resident #25 did not have a diagnosis of Dementia and the interventions on the behavior care plan were not person centered. During an interview on 3/26/2024 at 2:04 PM, the DON confirmed the care planned interventions were not person-centered for Resident #25 and the resident did not have a diagnosis of Dementia.

Based on review of the facility policy, observations, and interviews, the facility failed to maintain hand hygiene practices for 4 of 6 rooms on 1 hallway (Covid-19/Quarantine hallway) of 3 hallways observed, having the potential to affect 4 of 6 residents on the Covid-19/Quarantine hallway. The findings include: The Covid-19/Quarantine hallway had 6 residents being observed for 14 days due to new admissions from hospitals or readmissions. They had tested negative for Covid-19 prior to admission and were unvaccinated. The facility had no positive Covid-19 cases in the facility. Review of the facility policy, Hand Hygiene, dated 12/4/2020 showed .Handwashing/hand hygiene is .considered the most important single procedure for preventing .infections .hand hygiene is performed .between residents .during care . During an observation on 7/12/2021 at 12:36 PM, Certified Nursing Assistant (CNA #1) donned (put on) an isolation gown, delivered the food tray to room [ROOM NUMBER], touched the door handle, entered the room, set the tray up, doffed (removed) an isolation gown, touched the trash barrel lid, and exited the room. CNA #1 failed to perform hand hygiene prior to entering or exiting room [ROOM NUMBER]. During an observation on 7/12/2021 at 12:37 PM, CNA #1 donned a new isolation gown, retrieved the food tray from the cart and delivered the food tray to room [ROOM NUMBER], touched the door handle, entered the room, set the tray up, doffed the isolation gown, touched the trash barrel lid, and exited the room. CNA #1 failed to perform hand hygiene prior to entering or exiting room [ROOM NUMBER]. During an observation on 7/12/2021 at 12:39 PM, CNA #1 donned a new isolation gown, retrieved the food tray from the cart and delivered the food tray to room [ROOM NUMBER], touched the door handle, entered the room, set the tray up, doffed the isolation gown, touched the trash barrel lid, and exited the room. CNA #1 failed to perform hand hygiene prior to entering or exiting room [ROOM NUMBER]. During an observation on 7/12/2021 at 12:42 PM, CNA #1 donned a new isolation gown, retrieved the food tray from the cart and delivered the food tray to room [ROOM NUMBER], touched the door handle, entered the room, set the tray up, exited the room, and doffed the isolation gown in hallway. CNA #1 re-entered room [ROOM NUMBER] to discard the isolation gown in the garbage can, touched the lid of the garbage can, and exited the room. CNA #1 failed to perform hand hygiene prior to entering or exiting room [ROOM NUMBER]. During an observation on 7/12/2021 at 12:44, CNA #1 retrieved a plastic lid from the floor and discarded it in the trash. CNA #1 failed to perform hand hygiene after picking up the plastic lid from the floor. During an interview on 7/12/2021 at 12:51 PM, the Infection Control Practitioner (ICP) stated he expected hand hygiene to be performed when entering and exiting isolation rooms. During an interview on 7/12/2021 at 2:30 PM, CNA #1 confirmed she failed to perform hand hygiene between the patient rooms while delivering food trays on the Covid-19 quarantine hallway. During an interview on 7/14/2021 at 11:30 AM, the Director of Nursing (DON) stated she expected hand hygiene to performed upon entering and exiting resident rooms, especially isolation rooms.

Based on medical record review and interview, the facility failed to maintain an accurate medical record for 1 resident (#174) of 29 residents reviewed for medical records. The findings include: Medical record review showed Resident #174 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Tennessee Physicians Orders for Scope of Treatment (POST) form dated [DATE] showed .Do Not Attempt Resuscitation (DNR/no CPR) [cardiopulmonary resuscitation] .Comfort Measures .No artificial nutrition by tube . Review of the Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] .Enteral Feed Order every shift .via pump .Full Code with Full Treatment . During an interview on [DATE] at 3:55 PM, the Director of Nursing confirmed the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on medical record review and interview, the facility failed to refer 1 resident (#86) identified with possible serious mental disorders to the state-designated authority for a Level II Pre-Admission Screening and Resident Review (PASARR) of 5 residents reviewed for PASARR of 21 sampled residents. The findings include: Medical record review revealed Resident #86 was admitted to the facility on [DATE] with diagnosed including: [DIAGNOSES REDACTED]. Continued review revealed [DIAGNOSES REDACTED]. Medical record review of a PASARR Level I assessment dated [DATE] revealed Resident #86 had no [DIAGNOSES REDACTED]. Interview with Registered Nurse #1 on 2/27/19 at 8:55 AM, in the Conference room, confirmed a new PASARR had not been completed to include the [DIAGNOSES REDACTED].#86.

Based on facility policy review, observation and interview, the facility failed to follow the facility's policy for infection control for isolation for 1 Resident (#78) of 36 residents reviewed on 1 hallway of 4 hallways reviewed for infection control. The findings included: Facility policy review for infection control regarding [MEDICAL CONDITION] (infection of the colon) revised 4/2017 revealed .Gowns and gloves are removed before leaving the resident's room and hands must be washed immediately following . Observation on 4/10/18 at 2:00 PM revealed laundry staff member #1 exited Resident #78's isolation room wearing isolation attire. Continued observation revealed laundry staff #1 stood outside Resident #78's isolation room door, removed gown and mask and placed used isolation attire under the left arm. Further observation revealed Laundry Staff #1 donned a new pair of gloves without washing the hands, opened Resident #78's door and discarded items in the isolation barrels. Observation on 4/11/18 at 9:00 AM revealed Laundry Staff #1 entered Resident #78's isolation room with donned isolation attire. Continued observation revealed the employee exited the room at 9:03 AM wearing isolation attire, closed resident #78's door, and stood outside the resident's room, removed gown, mask and gloves, rolled up the used isolation attire and placed under the left arm against clothing. Continued observation revealed Laundry Staff #1 donned a new pair of gloves without washing the hands, opened Resident #78's door and discarded the used attire in an isolation barrel. Further observation revealed Laundry Staff #1 closed Resident #78's room door, failed to wash the hands, and transported linens in barrels down the hallway. Interview with Laundry Staff #1 on 4/11/18 at 11:05 AM, in the laundry room, confirmed on 4/10/18 and 4/11/18 she exited Resident #78's isolation room, failed to remove isolation attire inside the resident's room, and placed the dirty attire under the left arm. Continued interview confirmed the employee donned a new pair of gloves without washing the hands. Further interview confirmed the employee failed to wash the hands immediately after removing the isolation attire and waited to wash the hands until return to the laundry room. Interview with the Director of Nursing (DON) on 4/11/18 at 11:15 AM, in the DON office, confirmed isolation attire is to be removed inside the isolation room and hands are to be washed immediately before leaving the residents room. Further interview confirmed the facility's infection control policy regarding [MEDICAL CONDITION] had not been followed.

Based on facility policy review, medical record review, a maintenance record review, review of an informal facility report, review of the Incident Tracking Report, observation and interview, the facility's Quality Assurance Committee failed to investigate and identify safety concerns related to an elopement of 1 resident (#128) of 1 resident reviewed for wandering behavior. The findings included: Review of the facility policy Elopement Policy, revised 4/2009, revealed .Definition of Elopement: Elopement occurs when a resident leaves the premises or a safe area without authorization . Continued review revealed a Decision Tree was included in the policy with an indication to investigate if staff were not aware a resident left the facility. Medical record review revealed Resident #128 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the maintenance records revealed the temporary public access/exit site had was established on 09/16/16, when the formal public access/exit was closed for use due to a motor vehicle accident. Review of an informal facility report, dated 10/3/16, revealed Resident #128 had exited the building from the temporary public exit, unaccompanied by staff, on 10/3/16. Continued review revealed visitors had called into the facility, after going to their car and observing Resident #128 on the front sidewalk of the facility. Review of the Incident Tracking report from 10/1/16-3/22/17, revealed the elopement on 10/3/16 was not included. Observation on 3/21/17 at 3:00 PM, of the public access/exit located off the main front hall of the facility, revealed a smaller hall which led to the front foyer of the facility. Continued observation revealed to the left of the small hall there was a beauty shop, to the right there was a conference room, and passage through double doors to the front foyer area that required pushing in on a bar across one of the doors to open. Observation revealed the door then automatically closed between uses. Continued observation revealed, directly in front of the double doors, the social services office, to the left the admissions office, and to the far right a door to administrative offices. Observation continued and revealed a slight right turn and ten steps led to double doors wired to a security system requiring a code to exit, followed by a second set of doors. Observation of the exit door, previously used as the temporary public access/exit, revealed it was accessed through 1 door, at the end of the long, front hallway. Continued observation revealed Resident #128's room was on the 200 Hall, the adjoining hall closest to the temporary exit. Interview with the maintenance director on 3/21/17 at 4:15 PM, in the conference room, revealed he was not sure of the exact date in November 2016 when the use of the front public access/exit resumed. Interview confirmed the side exit door, beyond the 200 Hall, was the temporary public access/exit from 9/16/16 through sometime up in November. Interview with the Administrator on 3/22/17 at 2:40 p.m., in the conference room, verified the facility had admitted Resident #128 during the period of time when the temporary public access/exit was in use. Interview continued and confirmed the elopement was not recorded on an incident report, although required by the Decision Tree included in the facility's policy. Continued interview confirmed the Administrator did not know the incident had occurred, an investigation wasn't done, and therefore the Quality Assurance Committee failed to identify safety concerns related to the temporary exit or any other possible contributing factors related to the elopement.

Based on facility policy review, observation, and interview the facility failed to properly clean and sanitize 1 of 2 shower chairs on Unit 2 available for use for 56 residents on Unit 2. The findings included: Review of the facility policy entitled Cleaning and Disinfection of Non-Critical Patient Care Equipment, revised 4/1/15, revealed, .patient care equipment is cleaned daily and before and after use . Observation of Unit 2 on 3/20/17 at 9:05 AM, revealed 2 bariatric shower chairs in the hallway, outside the shower room. Continued observation revealed dried brown debris around the rim of the shower chair seat and under the lid of the shower chair. Interview with Registered Nurse (RN) #1 on 3/20/17 at 9:12 AM, at the Unit 2 nurses station, revealed shower chairs were kept in the hallway during shower times, placed back into the shower room for storage, shower equipment was cleaned at the end of the day, and after every use. Continued interview and observation of the shower chair with RN #1 confirmed dried brown debris on the rim of the shower chair seat and under the lid of the shower chair. Further interview confirmed the facility's policy on cleaning and sanitizing equipment was not followed and the shower chair was available for resident use, allowing a risk for cross contamination.

Based on observation and interview, the facility failed to provide sanitary conditions in 1 of 2 resident nourishment rooms. The findings included: Observation of the Unit 1 resident nourishment room, with the Certified Dietary Manager (CDM), on 3/23/17 at 9:57 AM, revealed twenty-three 8 ounce (oz.) cans of [MEDICATION NAME] 1.2 calorie (a tube feeding liquid) with expiration dates of 8/2016, and one 8 oz. can of Glucerna 1.2 calorie (a tube feeding liquid) with an expiration date of 2/2016, available for use by residents. The CDM confirmed at the time of discovery, the 23 cans of [MEDICATION NAME] 1.2 and 1 can of Glucerna 1.2 were expired and should have been discarded.

Based on review of facility policy, medical record review, review of an informal facility report, and interview, the facility failed to notify the physician and the family of a change in condition related to elopement for 1 resident (#128) of 29 residents reviewed. The findings included: Review of the facility policy Elopement Policy, revised 4/2009, revealed .Definition of Elopement: Elopement occurs when a resident leaves the premises or a safe area without authorization (i.e., an order for [REDACTED].family and physician notification .reports findings and condition of the resident . Medical record review revealed Resident #128 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set ((MDS) dated [DATE], revealed a Brief Interview of Mental Status (BIMS) of 4 (severe cognitive impairment), Delusions (1 to 3 days), Wandering (1 to 3 days), and Wandering Impact yes (indicating the wandering placed the resident at significant risk of getting to a potentially dangerous place). Medical record review of Licensed Practical Nurse (LPN) #1's Progress Note, dated 10/3/16 at 6:47 PM, revealed .Found by CNA walking outside dining room, looking at foliage. DON (Director of Nursing) notified. Q (every) 15 min (minute) checks initiated . Medical record review of an informal facility report, dated 10/3/16, revealed Resident #128 exited the building, visitors going on to their car called the DON, and reported the resident outside in front of the dining room. Continued review revealed Certified Nursing Assistant (CNA) #3 brought the resident back into the facility, the DON ordered 15 minutes checks .for the next few days . and instructed LPN #1 to notify the family and Family Nurse Practitioner. Further review revealed 15 minutes checks performed from 5:15 PM on 10/3/16 through 11:00 PM on 10/8/16. Medical record review of Resident #128's Physician Orders revealed no orders for Resident #128 for 10/3/16 or 10/4/16. Continued review revealed no documentation of the elopement in the Physician's progress notes, the Social Service Director (SSD) notes, or the Care Plan Meeting notes, dated 10/14/16. Medical record review revealed no nursing documentation of the physician, physician extender, or family being notified of the elopement. Interview with LPN #1 on 3/21/17 at 3:50 PM, at the 200 Hall nursing station, confirmed she received a phone call on the evening of 10/3/16 from a CNA informing her Resident #128 was found outside the dining room, on the sidewalk at the front of the building, and she had been brought back into the facility. Further interview revealed LPN #1 telephoned the DON who instructed her to do 15 minute checks. Continued interview confirmed she did not notify the physician or the resident's family, I think I put it on the Nurse Practitioner's log. Interview with the SSD on 3/21/17 at 5:35 PM, in the conference room confirmed she saw Resident #128 outside the building, walking by the dining room window, but did not document the event or notify the family. Interview with the Administrator and the DON on 3/22/17 at 6:25 PM, in the conference room, confirmed the facility failed to notify the physician and the family of Resident #128's elopement.

Based on facility policy review, medical record review, review of an informal facility report, and interview, the facility failed to report and investigate an allegation of elopement for 1 resident (#128) of 1 resident reviewed for elopement. The findings included: Review of the facility policy Elopement Policy revised 4/2009 revealed Definition of Elopement: Elopement occurs when a resident leaves the premises or a safe area without authorization (i.e., an order for [REDACTED].if the staff were not aware of the resident leaving the facility, the facility is to conduct an investigation and report if neglect may have occurred . Medical record review revealed Resident #128 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Progress Notes dated 10/3/16 at 6:47 PM, revealed .Found by CNA walking outside dining room, looking at foliage. DON (Director of Nursing) notified. Q (every) 15 min (minute) checks initiated. No c/o (complaints) at this time .will continue to monitor . Medical record review of the informal facility report, dated 10/3/16, revealed Resident #128 had exited the building with a visitor who called the DON to report the resident was (outside) in front of the dining room. Medical record review of the admission Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview of Mental Status (BIMS) of 4 (severe cognitive impairment), Delusions (1 to 3 days), Wandering (1 to 3 days), and Wandering Impact yes (indicating the wandering placed the resident at significant risk of getting to a potentially dangerous place). Interview with the Social Service Director (SSD), on 3/21/17 at 2:45 PM, in the SSD office revealed she was responsible for entering the MDS information for BIMS and behaviors, including delusions and wandering. Further interview revealed .she would literally wander the entire building and attempt to follow the visitors out the door .in the fall .at dinnertime .she (Resident #128) walked out the door .I saw her, I was sitting in the dining room, and could see her out the window .CNA's (Certified Nursing Assistants) ran after her .the CNA's got her back in . Interview with the Administrator on 3/21/17 at 6:18 PM, in the conference room, confirmed he was not aware Resident #128 eloped from the facility without staff supervision. Interview continued and confirmed the facility failed to follow their policy to create an incident report, investigate the elopement, and report the elopement to the state.

Based on facility policy review, medical record review, facility records, and interview, the facility failed to conduct an investigation of a resident elopement, thereby failing to identify a root cause and any contributing factors for the elopement, for 1 resident (#128) of 1 resident reviewed for wandering. The findings included: Review of the facility policy Elopement Policy, revised 4/2009, revealed .Definition of Elopement: Elopement occurs when a resident leaves the premises or a safe area without authorization (i.e., an order for [REDACTED]. Medical record review revealed Resident #128 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set (MDS), dated [DATE], revealed a Brief Interview of Mental Status (BIMS) of 4 (severe cognitive impairment), Delusions (1 to 3 days), Wandering (1 to 3 days), and Wandering Impact yes (indicating the wandering placed the resident at significant risk of getting to a potentially dangerous place). Medical record review of Resident #128's initial Risk of Elopement/Wandering Review, dated 9/28/16, revealed .*per report, *possibly exit seeking behavior. Further review revealed .staff notified to keep close watch on resident's whereabouts . Medical record review of Resident #128 Interim Care Plan, dated 9/28/16, revealed Elopement risk: Wandering and/or exit seeking behaviors . Medical record review of a Progress Note, dated 10/3/16 at 6:47 PM, revealed .Found by CNA walking outside dining room, looking at foliage. DON (Director of Nursing) notified. Q (every) 15 min (minute) checks initiated. No c/o (complaints) at this time .will continue to monitor . Medical record review of Resident #128's Physician Orders revealed no orders for 10/3/16 or 10/4/16. Continued review revealed no documentation of the elopement in the Physician's progress notes, the Social Service Director (SSD) notes, or the Care Plan Meeting notes, dated 10/14/16. Record review of the Daily Stand up Meeting sign-in sheet, dated 10/4/16, revealed the signatures of the Administrator, the Director of Nursing (DON), the Social Service Director (SSD), MDS Coordinator, and the Housekeeper/Laundry Supervisor. Interview with the SSD, on 3/21/17 at 2:45 PM and at 5:25 PM, in the SSD office revealed .she would literally wander the entire building and attempt to follow the visitors out the door .in the fall .at dinnertime .she (Resident #128) walked out the door .I saw her, I was sitting in the dining room and could see her out the window .CNA's (Certified Nursing Assistants) ran after her .the CNA's got her back in . Interview with LPN #1 on 3/21/17 at 3:50 PM, at the 200 Hall nursing station, confirmed she received a phone call on the evening of 10/3/16 from a CNA informing her Resident #128 was found outside the dining room, on the sidewalk at the front of the building, and had been returned to the facility. Further interview confirmed LPN #1 telephoned the DON who instructed her to do 15 minute checks. Continued interview confirmed .I considered that a safety risk . and confirmed she did not complete an incident report. Interview with CNA #2 on 3/22/17 at 1:05 PM, in the conference room, confirmed on 10/3/17, on evening shift, she was asked by CNA #1 to help locate Resident #128. Continued interview confirmed she walked by the dining room and saw Resident #128 next to the bushes on the sidewalk. Interview revealed she and CNA #3 went outside and returned the resident to the facility. Further interview confirmed she was not asked any questions by the administration or asked to write a statement regarding the incident. Interview with CNA #3 on 3/22/17 at 1:20 PM, in the conference room, confirmed she observed Resident #128 outside the dining room windows. Continued interview confirmed she was not asked any questions by the administration or asked to write a statement regarding the incident. Interview with the Administrator and the DON on 3/22/17 at 2:30 PM, in the conference room confirmed there was no discussion on 10/4/16, at the morning stand-up meeting attended by department heads, of the elopement and the facility failed to investigate an elopement for a resident at risk for wandering and elopement from the facility.