Signature Healthcare at Jefferson Manor Rehab & We

Facility failed to follow policy prior to self-administering neb treatments.The findings include: Review of facility policy, Medication Administration Self-Administration by Resident, dated 01/2023, indicated, Residents who desire to self-administer medications are permitted to do so with a prescriber's order and if the nursing care center's interdisciplinary team has determined that the practice would be safe and the medications are appropriate and safe for self-administration. PROCEDURES 1. If the resident desires to self-administer medications, an assessment is conducted by the interdisciplinary team of the resident's cognitive, physical, and visual ability to carry out this responsibility, during the care planning process. The policy continued, The results of the interdisciplinary team assessment are recorded on the Medication Self-Administration Assessment, which is placed in the resident's medical record. Review of facility document, Resident Face Sheet indicated the facility admitted Resident #17 on 02/10/2025 with diagnoses including acute respiratory failure with hypoxia,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and review of facility policy, it was determined the facility failed to ensure drugs and biologicals were stored appropriately, without being expired, for one (1) of two (2) medication storage rooms, and two (2) of five (5) medication carts. A tour of the blue medication room, on 06/04/2024 at 11:45 AM, revealed a tube of Iodosorb with an expiration date of 02/2022, a tube of Medihoney with expiration date of 12/11/2022, and a tube of HydrofaraBlue with expiration date of 02/01/2021. Additionally, observation on 06/04/2024 at 12:50 PM, of the [NAME] Unit, Medication Cart #1, revealed the following expired medications: a bottle of nitroglycerine 0.4 milligram (mg) with an expiration date of 11/16/2023; Atrovent 17 micrograms (mcg ) hydrofluoroalkane (HFA) inhaler with an opened date of 04/24/2024; and a Miralax bottle opened on 01/29/2023. Furthermore, observation on 06/04/2024 at 1:35 PM, of the [NAME] Unit, Medication Cart #3, revealed the following expired medications: Breyna expired on 04/25/2024; and Glycopyrolate 1 milligram (mg)/5 milliliters…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, record review, and review of facility policy, it was determined the facility failed to ensure two (2) of 49 sampled residents (Resident (R)16 and R47) were assessed for self-administration of medications to ensure the practice was clinically appropriate. Observation on 06/03/2024 at 2:27 PM, revealed a bottle of Flonase Allergy Relief nasal spray on R16's overbed table. However, there was no documented evidence of Physician's Orders for self administration of medications. Additionally, observation, on 06/04/2024 at 12:37 PM, revealed a small yellow pill on R47's lunch tray. However, there was no documented evidence of Physician's Orders for self administration of medications. The findings include: Review of the facility's policy titled, Medication Administration Self-Administration by Resident, last reviewed on 01/2023, revealed Residents who desire to self-administer medications are permitted to do so with a prescriber's order and if the nursing care center's interdisciplinary team has determined that the practice would be safe, and the medications…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, review of the Centers for Medicare and Medicaid Services (CMS), Form Instructions for the Notice of Medicare Non-Coverage (NOMNC) CMS-10123, review of the CMS site, Form Instructions Advance Beneficiary Notice of Non-coverage (ABN) OMB Approval Number: 0938-0566 and review of facility policy, it was determined the facility failed to issue the appropriate notice for termination of Medicare part A benefits for two (2) of three (3) residents reviewed for beneficiary notification out of a total sample of 49 residents (Resident (R) 67 and R73). These failures had the potential to result in a lack of understanding of appeal rights and/or the termination of the current level of care against the resident's/representative's wishes. The findings include: Review of the Centers for Medicare and Medicaid Services (CMS), Form Instructions for the Notice of Medicare Non-Coverage (NOMNC) CMS-10123 accessed at…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview, record review and review of the Kentucky Board of Nursing AOS #09 - Wound Assessment, Staging, and Treatment published in December 2023, it was determined the facility failed to ensure services provided or arranged by the facility meet professional standards of quality for two (2) of 49 sampled residents (Resident (R)71 and R1). The facility failed to have qualified wound care staff and physician oversight related to wound care. The findings include: Review of the Kentucky Board of Nursing Advisory Opinion Statement (AOS) #09 - Wound Assessment, Staging, and Treatment published in December 2023, provided by the facility revealed, .It is within the scope of licensed practical nursing practice for a licensed practical nurse who is educationally prepared and clinically competent to assist the qualified healthcare provider in wound assessment, staging, and treatment including debridement. This includes the application of wound dressings and wound vacs, the removal of wound drains, and the application of Unna boots . Review of the job description provided by the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, record review, and review of facility policy, it was determined the facility failed to ensure that adequate assistive devices were implemented to prevent accidents for one (1) of four (4) sampled residents reviewed for falls out of a total sample of 49 residents, Resident (R)76). R76 was found on the floor on 04/20/2024, and the Interdisciplinary Team (IDT) conducted a root cause analysis and determined the resident attempted to get out of his bed and fell. A new fall intervention dated 05/04/2024, revealed the resident's bed was to be in a low position, when he was in bed. However, observations on 06/04/2024 revealed staff failed to ensure the bed was in the lowest position while the resident was in bed. The findings include: Review of the facility policy titled, Falls, dated 09/15/2023, indicated, .The intent of this policy is to ensure the facility provides an environment that is as free from accident hazards, as possible, over which the facility has control to prevent avoidable falls.All residents will have a fall risk assessment on…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, it was determined the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for two (2) of two (2) sampled residents observed for wound care out of a total sample of 49 residents, Resident (R)1 and R71. During observation of wound care for R71, on 06/04/2024, Wound Care Nurse (WCN)1 failed to implement infection control procedures as evidenced by failure to clean/disinfect the table top prior to placing a barrier in which to place wound supplies; failure to clean/disinfect scissors before using them to cut the Kerlix which she packed in the resident's wound; failure to wash hands and don new gloves after wound care and prior to cleaning/disinfecting the dirty scissors; and failure to wait three (3) minutes after disinfecting the scissors prior to placing them back into the treatment cart. Additionally, during observation of wound care for R1 on…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and facility policy review, it was determined the facility failed to store and serve food in accordance with professional standards for food service safety. Observation revealed expired milk in the refrigerator and record review revealed food temperatures and sanitation temperatures not documented. The findings include: Review of the facility's policy, Food Temperatures, revised 08/31/18, revealed food should be served at proper temperatures to ensure food safety and palatability. Staff was to record temperature readings on the Food Temperature Chart (Form 401) or Food Temperatures/Sanitation Combined Record (Form 401B) or other designated form at the beginning of tray line and the end of tray line. If temperatures did not meet acceptable serving temperatures, reheat the product or chill the product to the proper temperature. Take the temperature of each pan of product before serving. Review of the facility's policy, Food Storage, revised 09/14/18, revealed food items should be stored, thawed, and prepared in accordance with good sanitary practice.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and facility policy review, it was determined the facility failed to follow the care plan for one (1) of four (4) sampled residents, Resident #70. The facility assessed the resident was at risk for falls with an intervention to have the call light within reach. However, observation revealed the resident's call light was not functional. The findings include: Review of the facility's policy, Comprehensive Care Plans, revised 07/19/18, revealed a person-centered care plan was developed to include measurable objectives and timetables to meet the resident's medical, nursing, mental, and psychological needs. The care plan was designed to incorporate identified problem areas; incorporate risk factors associated with identified problems; and aid in preventing or reducing declines in the resident's functional status and/or functional levels. The policy revealed care plan interventions would reflect action, treatment, or procedures to meet the objectives toward achieving…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and facility policy review, it was determined the facility failed to ensure one (1) of four (4) sampled residents, Resident #70, had a functioning call light to ensure safety. Observation revealed the call light box/jack was pulled away from the wall and not functional. The findings include: Review of the facility's policy, Safety and Supervision of Resident, reviewed 05/31/18, revealed staff should make routine resident and environmental checks to ensure the safety and well-being of the resident. Routine resident checks by nursing staff involved entering the resident's room and/or identifying the resident elsewhere on the unit to determine if the resident's needs were being met, identify a change in the resident's condition, identify whether the resident had any concerns, see if the resident was sleeping, and needed toileting assistance, etc. Review of the facility's policy, Answering the Call Light, revised October 2010, revealed staff should ensure the call…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, facility policy review, and controlled mediation count review, it was determined the facility failed to account for controlled medication for one (1) of eighteen (18) sampled residents, Resident #26. Observation and record review revealed an inaccurate account of the resident's medication. The findings include: Review of the facility's policy, Medication Administration Controlled Substances, revised November 2017, revealed controlled medications were substances that fell under U.S. Drug Enforcement Agency (DEA) Schedule II-V, and had a potential for abuse, ranging from low to high, and might also lead to physical or psychological dependence. These medications were subject to special handling, storage, disposal, and record keeping at the facility in accordance with federal and state laws and regulations. The policy stated when a controlled medication was administered, the licensed nurse administering the medication immediately entered the date and time of administration, amount administered, and signature of the nurse administering the dose on the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and facility policy review, it was determined the facility failed to ensure proper storage of medications in two (2) of six (6) medication carts, [NAME] Hall Medication Carts 1 and 2. Observation revealed sixty-one (61) loose, unpackaged pills in the carts. In addition, Medication Cart #1 was left unlocked and unattended and medications were left unattended at Resident #37's bedside. The findings include: 1. Review of the facility's policy, Preparation for Medication Administration, dated October 2007, revealed the facility maintained equipment and supplies necessary for the storage, preparation, and administration of medications to residents. The nurse or authorized staff member on duty ensured equipment and supplies related to medication storage and use were clean and orderly. Review of the facility's policy, Medication Administration General Guidelines, dated December 2012, revealed medications were administered as prescribed in accordance with manufacturer's specifications, good nursing principles and practices, and only by persons legally…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to maintain an effective infection control program to help prevent the development and transmission of disease and infection for one (1) of six (6) sampled residents, Resident #13. Observation of Resident #13's Oxygen tubing revealed it was dated 07/11/18, several months prior to the survey. The findings include: Review of the facility's policy, Infection Control, revised October 2018, revealed the objectives of the infection control practices served to prevent, investigate, and control infections in the facility. The facility was to maintain a safe, sanitary environment for personnel, residents, visitors, and the general public. The policy further stated all personnel were trained on infection control policies and practices, upon hire and periodically, which included how and where to find and use pertinent procedures and equipment related to infection control. Review of Resident #13's clinical record revealed the facility re-admitted the resident on 10/13/18, with…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview, record review, and facility policy review, it was determined the facility failed to provide pneumococcal vaccinations to three (3) of eighteen (18) sampled residents, Resident #9, #22, and #70. The findings include: Review of the facility's policy, Pneumococcal Vaccine, revised August 2016, revealed all residents would be offered Pneumococcal vaccine to aid in preventing pneumonia/pneumococcal infection. Prior to or upon admission, residents should be assessed for eligibility to receive the pneumococcal vaccine series, and when indicated, would be offered the vaccine series within thirty (30) days of admission to the facility unless medically contraindicated or the resident had already been vaccinated. Assessments of pneumococcal vaccination status would be conducted within five (5) working days of the resident's admission if not conducted prior to admission. Record review revealed the facility admitted Resident #9 on 02/10/18. There was no evidence the resident received or declined a pneumococcal vaccination. Record review revealed the facility admitted Resident…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.