Jefferson County Nursing Home

Based on interviews, record reviews, and facility policy review, the facility failed to complete a significant change assessment and submit a required Level II Preadmission Screening and Resident Review (PASRR) for one (1) of two (2) residents reviewed for PASRR (Resident #16). Specifically, the facility failed to submit a PASRR Level II and complete a significant change assessment after Resident #16 was diagnosed with major mental illness, including bipolar disorder and Major Depressive Disorder, Recurrent, Severe with Psychotic Symptoms. Findings Include: A review of the facility's Pre-admission Screen policy revealed: Preadmission Screening and Resident Review (PASRR) aims to ensure individuals are not inappropriately placed in nursing homes for long-term care and to provide them with the services they need in those settings . A record review of Resident #16's Pre-admission Screen (PAS), dated 7/25/11, revealed no major mental illness at the time of screening. A record review of Resident #16's record revealed that a Level II PASRR was submitted on 4/1/22 related to an…

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 interviews, record reviews, and facility policy review, the facility failed to implement the comprehensive care plan as developed for one (1) of two (2) residents reviewed for skin conditions (Resident #34). Specifically, the facility failed to carry out weekly skin evaluations as required by the resident 's care plan and physician orders. Findings include: A record review of the facility's Comprehensive Care Plan policy with a revision date of 1/2025 revealed: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that include measurable objectives and time frames to meet a resident's medical, nursing . A record review of Resident #34's Comprehensive Care Plan initiated 4/22/25 revealed skin impairment related to moisture-acquired skin damage to the buttocks. The care plan directed staff to Monitor and Document weekly. A record review of Resident #34's weekly skin evaluations revealed they were not completed during April 2025. A record review of Resident #34's electronic…

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 interviews, record reviews, and facility policy reviews, the facility failed to ensure that care and services were provided in accordance with professional standards of practice for one (1) of two (2) residents reviewed for skin conditions (Resident #34). Specifically, the facility failed to ensure that weekly skin assessments were completed and documented as ordered by the physician and in accordance with facility policy, resulting in a lack of monitoring for skin breakdown. Findings include: A record review of the facility's Skin Assessment policy dated 1/2025 revealed: It is our policy to perform a full body skin assessment as part of our systemic approach to pressure injury, prevention and management. The policy includes the following procedural guidelines .: A full body, or head to toe, skin assessment will be conducted by a licensed or registered nurse upon admission, re-admission, and weekly thereafter. A record review of Resident #34's weekly skin evaluations revealed that they were not completed during April 2025. A record review of Resident #34's weekly skin…

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, record reviews, and facility policy reviews, the facility failed to ensure incontinent residents received appropriate care and services to prevent the possibility of a urinary tract infection for one (1) of two (2) residents observed for incontinent care (Resident #8). Specifically, the facility failed to provide timely incontinence care and maintain cleanliness, which placed the resident at risk for skin breakdown and urinary tract infection. Findings Include: A record review of the facility's Perineal Care policy with a revision date of 1/2025 revealed: It is the practice of this facility to provide perineal care to all incontinent residents during routine bath and as needed in order to promote cleanliness and comfort, prevent infection to the extent possible and to prevent and assess for skin breakdown . On 05/13/25 at 3:15 PM, an observation of peri-care being performed by Certified Nursing Assistant (CNA) #1, assisted by CNA #2, revealed CNA #1 removed Resident #8's brief, which was heavily soiled with amber-colored urine and emitted a strong…

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, staff interview, record review and service manual review the facility failed to assess residents for the risk of entrapment, obtain informed consent, and conduct routine preventative maintenance per the manufacturer's recommendations/specifications for bed rails for five (5) of fourteen (14) sampled residents. (Resident #4, #6, #28, #29 and #39) Findings Include: Observations of resident rooms on 1/23/24 from 10:00 AM to 12:17 PM, revealed Residents #4, #6, #28, #29, and #39 had beds that were the brand name of Basic American Matrix 709 Matrix II and had bilateral quarter (1/4) length bed rails. Review of the medical record for Residents #4, #6, #28, #29 and #39 revealed there were no resident entrapment risk assessments and no signed informed consent forms for the use of the bed rails. Record review of the Service Manual for Basic American's Matrix 709 Series, dated 2011, revealed, . When assessing the risk for entrapment, you need to consider your bed, mattress, head and footboards, half rails, assist bars, and other accessories for an entire system A…

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, record review, and facility policy review, the facility failed to protect a resident's right to be free from misappropriation of property and exploitation for one (1) of fourteen (14) sampled residents. Resident #40 Findings include: Review of the facility's policy titled, Abuse, Neglect and Exploitation, with a revision date of 4/17, revealed, Policy: Each resident has the right to be free from abuse, neglect, misappropriation of resident property and exploitation .Residents must not be subject to abuse by anyone, including, but not limited to; facility staff, other residents .Policy Explanation and Compliance Guidelines .9. Exploitation means taking advantage of a resident for personal gain through the use of manipulation, intimidation, threats, or coercion . A review of the facility's Vulnerable Adult Act, undated, revealed, .Any nursing home resident is considered to be a vulnerable adult .the following situation are considered CRIME OF ABUSE against vulnerable adults .theft or misuse of a resident's personal belongings, personal funds, or bank…

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 staff interview, record review, and facility policy review, the facility failed to provide appropriate corrective action to prevent further potential misappropriation and exploitation by allowing a Certified Nurse Aide (CNA #2) access to a previous victim (Resident #40) for one (1) of 14 sampled residents. Findings include: Review of the facility's policy, Abuse, Neglect and Exploitation, with a revision date of 4/2017, revealed, Policy: Each resident has the right to be free from abuse, neglect, misappropriation of resident property and exploitation .The facility must .8. Resident Protection after Alleged Abuse, Neglect and Exploitation-The facility will make efforts to protect all residents after alleged abuse, neglect and/or exploitation . A record review of the Reportable Incident Form dated 12/18/23, revealed the Director of Nursing (DON) began an investigation because Resident #40 reported that she had several incidents where she had given staff members money or allowed them to use her debit card. Resident #40 stated that she helped CNA #2 because she had three small…

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 record review and staff interviews, the facility failed to accurately complete the Minimum Data Set (MDS) reflecting anticoagulant medications for four (4) residents of twelve (12) sampled residents whose MDS Assessments were reviewed for accuracy. (Resident #1, Resident #10, Resident #20, Resident #36). Findings include: A record review of the facility's statement, dated 12/29/21 and signed by the Director of Nursing (DON) revealed, (Proper Name of facility) uses the Resident Assessment Instrument (RAI) manual for Minimum Data Set (MDS) completion. A record review of the Davis's Drug Guide for Nurses Fifteenth Edition 2015 revealed the classification of Clopidogrel (Plavix) is listed as therapeutic: antiplatelet agents and Pharmacologic: platelet aggregation inhibitors. On 12/29/21 at 2:29 PM, during an interview with Registered Nurse (RN) #2 MDS nurse, she reviewed the most recent MDS assessments as well as the corresponding Medication Administration Records (MARs) for Resident #1, Resident #10, Resident #20, and Resident #36 and confirmed they did not receive an…

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 observations, interviews, record review, and facility policy review, the facility failed to prevent the possible spread of infection by not changing gloves after removing a soiled dressing during wound care for one (1) of three (3) residents observed during wound care. (Resident #30). Findings include: Record review of the facility policy titled, Hand Hygiene Policy , reviewed 11/21, revealed, All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors .Hand Hygiene Table .After handling contaminated objects .Before and after handling clean or soiled dressings, linens, etc After handling items potentially contaminated with blood, body fluids, secretions, or excretions . (marked X) Either Soap and Water or Alcohol Based Hand Rub . Record review of the facility policy titled Infection Prevention and Control Program Policy dated 8/21, revealed .4. Standard Precautions: .b. Hand hygiene shall be performed in accordance with our…

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.