Signature Healthcare at Jefferson Place Rehab & We

Based on observation, interview, and review of the facility policy, it was determined the facility failed to serve food under sanitary conditions. Dietary Aide (DA)2 failed to perform hand hygiene after touching various items, and prior to serving food. In addition, DA2 failed to wear a finger cot over a wound to prevent possible contamination while handling food. The findings include: Review of the facility policy Food Preparation dated 09/2017, revealed all staff will practice proper handwashing techniques and glove use. Dining services staff will be responsible for food preparation procedures that avoid contamination by potentially harmful physical, biological, and chemical contamination. Observation on 06/17/2025 at 11:15 AM, revealed DA2 was obtaining temperatures (temping) of several items on the food line. DA2 who had a band-aid on one finger, was not wearing gloves. He then stepped away from the food line and walked over to a bucket and, using his bare hands, pulled out a wet cloth from the bucket. DA2 then walked back to the food line, and wiped down the shelf above 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 the facility's policy, it was determined the facility failed to store, prepare, and distribute food under sanitary conditions and in accordance with professional standards for food safety. Initial tour of the facility revealed opened and undated containers of salad dressing in the walk-in refrigerator. The findings include: Review of the facility's policy, Labeling and Dating Policy, dated 2017, revealed proper labeling and dating ensured all foods were stored, rotated, and utilized in a first in, first out manner. This helped minimize waste and ensured items past their due date were discarded. Tour of the kitchen with the Dietary Manager, on 09/12/2021 at 10:00 AM, revealed two (2) salad dressing containers that were opened, but were not dated in the walk-in refrigerator. Interview with the Dietary Manager (DM), on 09/12/2021 at 10:00 AM, revealed food and drinks needed to be labeled so that staff would know when they were first opened. She stated food and drinks should be labeled and dated with the date opened and when…

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 and policy review, it was determined the facility failed to maintain an infection prevention and control program that ensured a safe, sanitary, and comfortable environment for the prevention of communicable diseases and infections. Observations during the survey revealed direct care staff, housekeeping staff, compassionate care staff, and one (1) resident did not consistently utilize masks and/or eye protection, as currently required when working in, or traveling through resident care areas. The findings include: Review of the facility's policy titled Infection Control, revised October 2018, revealed the facility's infection control policies and practices applied equally to all personnel, consultants, contractors, residents, visitors, volunteer workers, and the general public. Review of the facility's policy titled, Novel Corona Virus (COVID-19), last revised 09/13/2021, revealed under subheading General Prevention Measures, during the pandemic, the facility required all…

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 review of facility policy, it was determined the facility failed to ensure reasonable accommodations for one (1) of seventy-four (74) sampled residents (Resident) #79, on two (2) occasions. Observations of Resident #79 during survey revealed the call light button out of reach of the resident. The findings include: The facility did not provide a policy for accommodation of residents' needs. Review of Resident #79's medical records revealed the facility admitted the resident on 10/27/2020 with diagnoses of Cerebral Palsy, Seizures, Intestinal Obstruction, History of Urinary Tract Infection (UTI), Malignant Neoplasm of colon, Aphasia, and Sepsis. Review of Resident #79's Quarterly Minimum Data Set (MDS) dated [DATE] revealed the facility assessed the resident as absent of the spoken word and somewhat had the ability to understand others. A Brief Interview for Mental Status (BIMS) examination was not completed at this time; no BIMS was present in Resident #79's…

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, interviews, and policy review, it was determined the facility failed to ensure food was heated and held on the steamtable at safe temperature levels, which created the risk for foodborne illness. Observation of food temperatures revealed the ground beef temperature was 130 degrees F. In addition, during food temperature testing, the Dietary Manager failed to wash her hands prior to the testing process. The findings include: Review of the facility's policy, Food Temperatures, revised 01/04/19, revealed foods should be served at proper temperatures to insure food safety and palatability. Acceptable serving temperatures for meat was => 140 degrees F; however, the preferable temperature range was 140-165 degree F. Further review revealed the Food and Drug Administration Food Code allowed 135 degrees as the minimum hot holding temperature. The policy stipulated reheating food for hot holding had to reach 165 degrees F and had to hold this temperature for 15 seconds. Reheating of food by dietary staff was done within a two (2) hour period. Review of the facility's…

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 review of the facility's policies, it was determined the facility failed to have an effective system to safeguard, control, and account for controlled medications for three (3) of nineteen (19) sampled residents, Resident #9, #33 and #36. Review of Controlled Drug Records and Medication Administration Records (MAR) revealed the residents' controlled medications were not maintained and accurately reconciled to ensure the residents received their medications. The findings include: Review of the facility's policy, Controlled Medication and Drug Diversion, reviewed [DATE], revealed medication included in the Drug Enforcement Administration (DEA) classified as controlled substances were subject to special handling, storage, disposal, and recordkeeping with the facility in accordance with federal, state and other applicable laws and regulations. A controlled medication accountability record was prepared when receiving or checking in a Schedule II, III, IV, or V…

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 maintain an accurate clinical record related to medication administration for four (4) of nineteen (19) sampled residents, Residents #9, #30, #33, and #36. The findings include: Review of the facility's policy, Medication Administration, dated September 2018, revealed the individual who administered the medication dose should record the administration on the resident's Medication Administration Record (MAR) immediately following the medication being given. In no case should the individual who administered the medications report off-duty without first recording the administration of any medication. When as needed (PRN) medications were administered, the following documentation should be provided: the date and time of administration, dose, route of administration (if other than oral), and if applicable, the injection site; complaints or symptoms for which the medication was given; results achieved from giving the dose and the time results were noted; and signature or initials of 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, it was determined the facility failed to accommodate residents' needs for one (1) of nineteen (19) sampled residents, Resident #221. Observation revealed the resident's urinal was not within reach of the resident while he/she was in bed. The findings include: Review of the facility's Resident Rights, dated 08/16/18, revealed residents were treated in a manner and in an environment that promoted maintenance or enhancement of quality of life. Review of the clinical record revealed the facility admitted Resident #221 on 02/15/19, with diagnoses of Diabetes Type 2, Muscle Weakness, Local Infection of Subcutaneous Tissue, and Open Wound to the Left Foot. Review of the admission Minimum Data Set (MDS), dated [DATE], revealed the resident required extensive assistance from two (2) staff for toileting. The resident was frequently incontinent of bowel and bladder. The facility assessed the resident with a Brief Interview for Mental Status (BIMS) score of fifteen (15) of…

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 ensure the care plan was implemented related to behavior management for one (1) of three (3) sampled residents, Resident #30. Staff did not implement behavioral interventions prior to administration of a psychotropic medication (Ativan). The findings include: Review of the facility's policy, Comprehensive Care Plans, revised 07/09/18, revealed a person-centered comprehensive care plan that included measurable objectives and timetables to meet the resident's medical, nursing, mental, and psychological needs would be developed for each resident. The policy stated care plan interventions would address the underlying source(s) of the problem area(s) and reflect action, treatment, or procedure to meet the objectives toward achieving the resident goals. Observation, on 03/06/19 at 11:31 AM, revealed Resident #30 sitting up in bed with his/her eyes closed. Review of the clinical record revealed the facility admitted Resident #30 on 06/04/18, with diagnoses to include…

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, and record review, it was determined the facility failed to provide showers and grooming to one (1) of nineteen (19) sampled residents, Resident #221. The findings include: The facility did not provide a policy for resident showers. Review of the facility's Resident Rights, dated 08/16/18, revealed residents were treated in a manner and in an environment that promoted maintenance or enhancement of quality of life. Review of the clinical record revealed the facility admitted Resident #221 on 02/15/19, with diagnoses of Diabetes Type 2, Muscle Weakness, Local Infection of Subcutaneous Tissue, and Open Wound to the Left Foot. Review of the admission Minimum Data Set (MDS), dated [DATE], revealed the resident required extensive assistance from two (2) staff for personal hygiene and physical assistance of one (1) staff for bathing. The facility assessed the resident was interviewable with a Brief Interview for Mental Status (BIMS) score of fifteen (15) of fifteen (15). Review of 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.

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 three (3) sampled residents, Resident #30, was free from unnecessary psychotropic medication. Nursing staff did not monitor behaviors or implement non-pharmacological interventions prior to administration of a psychotropic medication (Ativan). The findings include: Review of the facility's Behavior Management Program Overview, not dated, revealed the purpose of the program was to identify and assess for disruptive behaviors in residents in order to develop interventions as appropriate. The policy revealed nursing staff should document each episode of the resident's behavior, precipitating factors, interventions, and outcomes of the interventions with noted side effects of psychoactive medications using the flow record in the Medication Administration Record (MAR). Further review revealed the Clinical Nurse Manager was responsible to ensure the licensed nurses completed 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 maintain an effective infection control program to help prevent the development and transmission of disease and infection for one (1) of nineteen (19) sampled residents, Resident #62. Observation of medication pass revealed Licensed Practical Nurse (LPN) #4 dropped a pill on the medication cart, used her bare fingers to pick up the pill, and put the pill into the medication cup, and administered the medication to Resident #62. In addition, the nurse failed to perform hand hygiene during medication administration. The findings include: Review of the facility's policy, Handwashing/Hand Hygiene, revised August 2015, revealed all facility personnel was trained and regularly in-serviced on the importance of hand hygiene to prevent the transmission of healthcare-associated infections and followed the handwashing/hand hygiene procedures to help prevention and spread of infections to other personnel, residents, and visitors. The policy stated hand washing was required before and after…

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.