Lauderdale Community Living Center

Inspectors wroteBased on (Named Glucometer-a device/meter used to check blood sugar levels with the use of a blood sample) User's Guide review, policy review, job description review, medical record review, observation, and interview, the facility failed to ensure practices to prevent the potential spread of infection were maintained when a multi-use blood glucose meter was not cleaned and disinfected with an Environmental Protection Agency (EPA) approved disinfecting wipe to prevent the cross-contamination of bloodborne pathogens for 2 of 2 (Residents #2 and Resident #15) sampled residents reviewed for blood glucose monitoring. Licensed Practical Nurse (LPN) A failed to clean and disinfect the multi-use blood glucose meter before and after use on each resident in accordance with User's Guide recommendations and facility policy. [...]

Inspectors wroteBased on policy review, medical record review, employee timesheets, and interview, the facility failed to provide sufficient nursing staff with appropriate competencies and skill sets to ensure residents attain or maintain the highest level of practicable physical well-being when the facility failed to ensure that a Cardiopulmonary Resuscitation (CPR) certified staff member was working 24 hours per day for 16 of 40 days reviewed. The facility had a census of 35 upon entrance.

Inspectors wroteBased on policy review, employee time sheet review, State of Tennessee Department of Health Division of Health Licensure website review, and interview the facility failed to ensure a Registered Nurse (RN) was on duty for at least 8 consecutive hours a day, 7 days a week, for 15 of 54 days reviewed and failed to ensure the Director of Nursing (DON) had a current and active nursing license from [DATE]-[DATE].

Inspectors wroteBased on daily staffing sheet review, observation, and interview, the facility failed to post daily staffing sheets that included the number of actual hours worked by each discipline for 31 of 31 days.

Inspectors wroteBased on policy review, observation, and interview, the facility failed to provide sufficient staff with the competencies and skill sets to carry out the functions of the food and nutrition services when there was not a Dietary Manager employed in the kitchen. The facility had a census of 35 with 35 of those residents receiving a meal tray from the kitchen.

Inspectors wroteBased on facility menu review, observation, and interview, the facility failed to serve food items from the menu posted for 3 out of 3 days reviewed during the recertification survey. The census was 35 with 35 residents receiving meals.

Inspectors wroteBased on policy review, observation, and interview, the facility failed to ensure food was stored, handled, prepared, and served under sanitary conditions, when large plastic containers holding dry food items revealed dried substances and loose particles on top of the lids and down the sides of the containers; when stainless steel tables, metal storage racks, and the steam table shelf, were found with dried, splattered substances on their surfaces; and when the walk in dry storage area had a dried white powdery substance on the floor and on top of 2 brown boxes located on a shelf. The outside of the ICE machine contained dried liquid spills down the front and both sides and the inside of the ICE machine contained several white streaks running down the inside walls around the door area. Clean dishes were stored in an area where dirty dishes were being washed. [...]

Inspectors wroteBased on review of Quality Assurance and Performance Improvement (QAPI) Performance Improvement Plan meeting minutes, policy review, observation and interview, the QAPI Committee failed to recognize ongoing problems of inadequate supervision, failed to provide oversight to ensure an effective Infection Control Program was in place that protected residents from cross contamination and failed to ensure staff were competent in providing resident care. The QAPI committee failed to identify the root cause of the problems identified, failed to develop appropriate plans to correct the identified problems, failed to ensure systems and processes were implemented to address, correct, and maintain acceptable standards of practice, and failed to provide clinical guidance and oversight regarding the implementation of resident care policies and procedures. [...]

Inspectors wroteBased on policy review, medical record review, observation, and interview, the facility failed to implement interventions on the care plan for 1 of 5 (Resident #25) sampled residents reviewed for Hydration and Nutrition.

Inspectors wroteBased on policy review, medical record review, and interview, the facility failed to conduct a care plan conference with the family representative for 1 of 7 (Resident #8) sampled residents reviewed.

Inspectors wroteBased on policy review, medical record review, observation, and interview the facility failed to provide care and services to assess, treat and prevent the spread of infection for 1 of 2 (Resident #36) sampled residents reviewed for pressure ulcers.

Inspectors wroteBased on policy review, medical record review, observation, and interview, the facility failed to provide an environment free of accident hazards when nursing staff left a razor open and unattended on a bedside table for 1 of 35 (Resident #2) residents reviewed.

Inspectors wroteBased on facility policy review, Centers for Medicare and Medicaid (CMS) Payroll-Based Journal (PBJ) Staffing Data Report, employee timesheet review, and interview the facility failed to ensure sufficient nursing staff to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident during the 2nd quarter (1/1/2025-3/31/2025) for 8 of 26 days reviewed. The facility census upon entrance was 35.

Inspectors wroteBased on policy review, Pharmacy Executive Summary review, observation, and interview, the facility failed to ensure medications were properly stored and secured when refrigerated medications were stored outside of the recommended temperature range for 1 of 1 medication refrigerator observed, when 2 nurses (Licensed Practical Nurse (LPN) A and LPN E) left medications unattended in 1 of 1 medication room, and when one of two (B Hall Medication Cart) medication carts was left unsecured and unattended.

Inspectors wroteBased on medical record review and interview, the facility failed to provide Behavioral Health Training to staff caring for 3 of 3 (Resident #8, #25, and #30) sampled residents reviewed for Dementia.

Inspectors wroteBased on policy review, medical record review, facility investigation review, timeanddate.com weather website review, police report review, observation, and interview, the facility failed to provide adequate supervision to ensure the resident environment was free of accident hazards for 1 of 3 (Resident #1) residents reviewed with wandering/exit seeking behaviors. On 2/9/2025 between 7:00 PM and 7:20 PM, Resident #1, a vulnerable resident with Dementia, who experienced hallucinations, exit seeking behaviors and was cognitively impaired, eloped through an unlocked and unsecured door that malfunctioned on C Hall. [...]

Inspectors wroteBased on policy review, observation, and interview, the facility failed to ensure medications were properly and securely stored when medications were left in residents' rooms for 4 of 34 (Resident #9, #19, #28, and #30 ) sampled residents, and 1 of 4 medication storage areas were left unlocked and unattended by (Licensed Practical Nurse (LPN) B), and when opened, undated, and expired medications were noted in 1 of 1 medication storage rooms.

Inspectors wroteBased on policy review, observation, and interview, the facility failed to ensure that food was prepared, and served under sanitary conditions when the oven door had a brown dried liquid on the glass, on the top of the oven door, carbon build up on the frying pans, a rusted mesh skimmer, steam table pans wet nesting on top of other table pans, and top of the convection oven and doors had a shiny film. The facility had a census of 34 with 34 of those residents receiving a meal tray from the kitchen.

Inspectors wroteBased on policy review, observation and interview, revealed the facility failed to ensure infection control practices were followed for 2 of 6 sampled residents (Resident #9 and #27) during medication administration when 2 of 5 nurses Licensed Practical Nurse (LPN) D and Registered Nurse (RN) C) failed to perform hand hygiene during administration of medications, and when RN C failed to sanitize reusable equipment after exiting a residents room with enhanced barrier precautions.

Inspectors wroteBased on policy review, medical record review, observation and interview, the facility failed to accurately assess residents with wandering for 1 of 12 residents (Resident #32) reviewed for accuracy of assessments.

Inspectors wroteBased on policy review, medical record review, and interview, the facility failed to ensure foot care/treatment provided for high risk residents was appropriate for 1 of 5 (Resident #5) sampled residents reviewed.

Inspectors wroteBased on policy review, medical record review, and interview, the facility failed to maintain an accurate medical record related to medication administration for 1 of 4 (Resident #9) sampled residents reviewed for medications.

Inspectors wroteBased on policy review, medical record review and interview, the facility failed to ensure 1 of 14 sampled residents (Resident #20) or their families were invited to participate in planning their care.

Inspectors wroteBased on resident personal funds accounts review, policy review, medical record review, and interview, the facility failed to notify the family and/or resident when the amount in the resident's account exceeded the eligibility limit for 8 of 19 residents (Resident #2, #3 #4, #6, #7, #11, #12, and #21) personal fund account statements reviewed and failed to refund the residents' funds within 30 days of death or discharge for 2 of 3 sampled residents (Resident #232 and #233) reviewed for trust funds.

Inspectors wroteBased on policy review, personnel file review, Employee Time Card review, and interview, the facility failed to ensure the abuse registry screening, criminal background screening, and reference checks were completed for 4 or 5 sampled employees (Social Services, the Wound Care/Registered Nurse (RN), Dietary Aide #1, and the Business Office Manager (BOM)) prior to hire.

Inspectors wroteBased on policy review, medical record review, observation and interview the facility failed to ensure Physicians' Orders were followed for medication administration for 1 of 5 sampled residents (Resident #23) reviewed for unnecessary medication and 1 of 2 sampled residents (Resident #27) observed for medication administration through a Percutaneous Endoscopic Gastrostomy (PEG) Tube.

Inspectors wroteBased on policy review, medical record review, observation, and interview, the facility failed to follow Physicians' Orders for Percutaneous Endoscopic Gastrostomy (PEG) tube for 1 of 2 sampled residents (Resident #5) reviewed for enteral feedings.

Inspectors wroteBased on policy review, facility documentation review, observation, and interview, the facility failed to update and post the Daily Nursing Staff Postings for 9 of 40 (2/27/2023, 2/28/2023, 3/6/2023, 3/7/2023, 3/8/2023, 3/9/2023, 3/10/2023, 3/11/2023, and 3/12/203) days reviewed.

Inspectors wroteBased on policy review, medical record review, observation and interview the facility failed to ensure practices to prevent the potential spread of infection were maintained when 1 of 2 staff members (Licensed Practical Nurse (LPN) #2) failed to perform hand hygiene during Percutaneous Endoscopic Gastrostomy (PEG) tube site care and failed to have a program in place to monitor for and prevent the growth of Legionella Disease and other opportunistic pathogens in the water system.

Inspectors wroteBased on review of staff in-services and interview the facility failed to ensure the mandatory annual 12 hours of Certified Nursing Assistant (CNA) in-service training hours were completed for 3 of 3 sampled CNA's (CNA #3, #4, and #5) reviewed for in-servicing.