Tennova Lafollette Health and Rehab Center

In the surveyor’s words

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

• Immediate jeopardy, isolatedF689Jul 29, 2022

  Amended 9/2/2022 to reflect change to Past Noncompliance. Based on facility policy review, medical record review, facility investigation review, observation, and interview, the facility failed to implement interventions to prevent elopement for 1 resident (Resident #1) of 3 residents reviewed for wandering and elopement. The facility's failure placed Resident #1 in Immediate Jeopardy (a situation in which a provider's non-compliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) when Resident #1 exited the 2nd floor of the healthcare center via an elevator to the first floor, where she was then assisted by a staff member out of a set of locked doors that led to the adjacent hospital. […]

• Immediate jeopardy, isolatedF689Apr 29, 2021

  Based on facility policy review, medical record review, facility investigation review, observation, and interview, the facility failed to follow their elopement policy, failed to implement interventions to prevent elopement, and failed to provide a safe environment to prevent an elopement for 1 of 4 sampled residents (Resident #3) reviewed for elopement. The facility's failure placed Resident #3 in Immediate Jeopardy (a situation in which a provider's non-compliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) when Resident #3 was able to enter the security code into the keypad and exit through an egress door to the facility's courtyard, and through the fence of the courtyard. […]

• No harm, potential for more than minimal, widespreadF812Apr 6, 2022

  Based on facility policy review, temperature log review, observation, and interview, the facility failed to maintain an appropriate temperature in the freezer and failed to ensure temperature logs were maintained for the refrigerator and freezer in 1 of 2 nourishment rooms which had the potential to affect 55 of 56 residents in the facility. The findings include: Review of the facility's policy titled, NURSING UNIT STOCK, dated 1/2022, showed .Nursing personnel are responsible for the once daily temperature monitoring of unit refrigerator(s) on a posted temperature sheet .If the refrigeration unit includes a freezer, the temperature in the freezer is also recorded once daily (ideal temperature is 0 [degrees] F [Fahrenheit], but may go as high as 10 [degrees] F in the nursing pantries if… […]

• No harm, potential for more than minimal, isolatedF641Jul 1, 2026

  Based on Centers for Medicare and (&) Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual Version 1.20.1 review, observations, medical record review, and interviews, the facility failed to accurately code a Minimum Data Set (MDS) assessment for oral/dental status for 1 resident (Resident #28); failed to accurately code MDS assessments for Hospice services for 2 residents (Residents #32 and #3); and failed to accurately code a MDS assessment for Pre-admission Screening and Resident Review (PASRR) for 1 resident (Resident #10) of 19 residents reviewed for MDS assessments. […]

• No harm, potential for more than minimal, isolatedF880Jul 1, 2026

  Based on the Association for Professionals in Infection Control (APIC) and Epidemiology's Guide to Hand Hygiene Programs for Infection Prevention review, medical record review, observation, and interviews, the facility failed to use appropriate hand hygiene practices when providing wound care to 1 resident (Resident #10) of 1 resident reviewed with an in-house pressure wound. The findings include:Review of the Association for Professionals in Infection Control [APIC] and Epidemiology's Guide to Hand Hygiene Programs for Infection Prevention, dated 6/2015, revealed .Hand hygiene is widely recognized as the most important measure to prevent the spread of infection .Hand hygiene is one of the cornerstones of reducing healthcare-associated infections and preventing occupationally acquired… […]