Complete Care at Jefferson Meadows LLC

Inspectors wroteBased on interview, record review, document review, and policy review, the facility did not ensure to prevent a resident elopement for one of four residents (Resident (R) 2) reviewed for wandering risks out of a total sample of eight residents. R2 exited the alarmed facility door, while unsupervised.

Inspectors wroteExample 2 The facility policy titled Weight Monitoring dated 2/2025 states in part .1. The facility will utilize a systemic approach to optimize a resident's nutritional status. This process includes: a. Identifying and assessing each resident's nutritional status and risk factors b. Evaluating/ analyzing the assessment information c. Developing and consistently implementing pertinent approaches d. Monitoring the effectiveness of interventions and revising them as necessary .4. Interventions will be identified, implemented, monitored, and modified (as appropriate), consistent with the resident's assessed needs, choices, preferences, goals, and current professional standards to maintain acceptable parameters of nutritional status .6. Weight Analysis: The newly recorded resident weight should be compared to the previous weight. A significant change in weight is defined as: a. [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure food was prepared and served in a safe and sanitary manner. This practice has the potential to affect all 48 residents who reside at the facility. Surveyor observed dietary staff directly touching food with bare hands. Surveyor observed staff enter kitchen area while food service was taking place, not wearing a hair restraint. Evidenced by: The facility policy, Food Safety Requirements, dated 2/25, states, in part; .7. Staff shall adhere to safe hygienic practices to prevent contamination of foods from hands or physical objects. a. Staff shall not touch food with bare hands, exhibiting appropriate use of gloves, tongs, deli paper, and spatulas .d. Dietary staff must wear hair restraints to prevent hair from contacting food . [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not assure drugs and biologicals used in the facility were stored and labeled in accordance with currently accepted professional practices and include the expiration date when applicable in 1 of 1 medication room. Surveyors observed the following: -6 stock antibiotic ointments were expired, found in the medication room: -3 antibiotic ointments (bacitracin zinc) expired on 12/22, 06/24, and 05/25 -1 triple antibiotic ointment (bacitracin zinc / neomycin sulfate / polymyxin B sulfate) expired on 12/23 and 2 expired on 01/25 Evidenced by: The facility policy, Medication Storage, dated 2/2025, states in part: Policy: It is the policy of this facility to ensure all medications house on our premises will be stored in the pharmacy and/or medication rooms according to the manufacturer's recommendations .8. Unused Medications: [...]

Inspectors wroteBased on interview and record review, the facility did not maintain medical records on each resident that are complete, accurately documented, readily accessible, and systematically organized in accordance with accepted professional standards and practices in 13 of 13 residents reviewed (R26, R3, R41, R21, R19, R31, R13, R42, R36, R25, R20, R5, & R15). The facility did not have readily accessible MD/NP visit notes for R26, R3, R41, R21, R19, R31, R13, R42, R36, R25, R20, R5, and R15. Evidenced by: The facility policy titled Physician Visits and Physician Delegation dated 2/2025 states in part .1. The Licensed Nurse should: a. Track due dates of physician visits .f. Remind the physician to date and sign all order and write a progress note .3. The Director of Nursing or Designee should: a. Conduct monthly audits for timeliness of physician visits . [...]

Inspectors wroteBased on interview and record review the facility failed to ensure they followed standards of practice for an antibiotic stewardship program that includes antibiotic use protocols and a system to monitor antibiotic use for 1 of 17 sampled residents (R42) and 3 of 4 supplemental residents (R300, R16 and R11) reviewed for antibiotic stewardship. R300 had documented urinary symptoms. The facility did not verify that infection criteria was met or monitor symptoms and effectiveness of treatment following the start of an antibiotic. R42 started an antibiotic for urinary tract infection (UTI). The facility did not verify that infection criteria were met, monitor symptoms through time of order for antibiotic treatment, or monitor symptoms and effectiveness of treatment following start of antibiotic. R16 started an antibiotic for UTI. [...]

Inspectors wroteBased on interview and record review, the facility failed to protect a residents right to be free from verbal abuse by a visitor for 1 of 13 residents (R3) reviewed for abuse. R3 was verbally abused on multiple occasions while at the facility by R3's Activated Power of Attorney (POA). The facility failed to ensure measures were in place to prevent verbal abuse from reoccurring. It was reported that R3's POA was yelling at R3 in December 2024. The facility completed an investigation regarding a possible verbal abuse by R3's POA on 3/27/25 and 4/21/25. The facility did not add appropriate interventions to ensure R3 was free from abuse, did not update R3's care plan with interventions, and staff were not aware of the need for extra support and/or monitoring when R3's POA was in the facility. Evidenced by: The facility policy, Abuse, Neglect and Exploitation, dated 4/8/25, states, in part; . [...]

Inspectors wroteBased on interview and record review, the facility failed to immediately intervene when alleged verbal abuse was observed for 1 of 3 Residents (R3) involved in a facility reported incident. Staff heard an alleged verbal abuse altercation and failed to immediately ensure R3's safety. Evidenced by: The facility policy, Abuse, Neglect and Exploitation, dated 4/8/25, states, in part; .VI. Protection of Resident .The facility will make efforts to ensure all residents are protected from physical and psychosocial harm, as well as additional abuse, during and after the investigation. Examples include but are not limited to: A. Responding immediately to protect the alleged victim and integrity of the investigation; B. Examining the alleged victim for any sign of injury, including a physical examination or psychosocial assessment if needed; C. [...]

Inspectors wroteBased on interview and record review, the facility did not follow through with the appropriate steps of the Preadmission Screening and Resident Review (PASSR) process for 2 of 5 residents (R23 and R20) reviewed for PASSR screening. R23 did not have a PASSR level I (1) completed. R20 did not have a PASSR level II (2) completed. This is evidenced by: The facility's Resident Assessment-Coordination with PASRR Program, dated 2/2025, states, in part: This facility coordinates assessments with the preadmission screening and resident review program under Medicaid to ensure that individuals with a mental disorder (MD), intellectual disability (ID), or a related condition receives care and services in the most integrated setting appropriate to their needs. Policy Explanation and Compliance Guidelines: 1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not provide an ongoing program of activities designed to meet the interests and the physical, mental, and psychosocial well-being of each resident. This affected 1 of 5 residents (R25) reviewed for activities. Surveyor observed R25 on 5/7/25 and 5/8/25 sitting in the hallway with no meaningful activities. Surveyor observed R25 on 5/7/25 at 9:41 am positioned staring at a wall. Surveyor observed R25 again at 10:46am, 11:20am sitting in same position. R25's daily activity documentation showed R25 napped and roamed the halls most days from January 2025-May 2025. Evidenced by: The facility policy, Activities, dated, 2/25, states, in part; .It is the policy of this facility to provide an ongoing program to support residents in their choice of activities based on their comprehensive assessment, care plan, and preferences. [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure residents who receiving nutrition and medication by G-tube (Gastrostomy tube, a thin flexible tube inserted through a small incision in the abdomen and into the stomach, used to provide nutrition and fluids) receive the appropriate treatment and services. This affects 1 of 1 residents (R42) reviewed for tube feedings. The facility did not properly check placement of R42's G-tube prior to administering tube feeding. This is evidenced by: The facility's policy entitled, Care and Treatment of Feeding Tubes, dated 4/2/25, states, in part: Policy: It is a policy of this facility to utilize feeding tubes in accordance with current clinical standards of practice, with interventions to prevent complications to the extent possible . 1. Feeding tubes will be utilized according to physician orders . 4. [...]

Inspectors wroteBased on observation, interview and record review, the facility did not comprehensively assess or develop a person-centered comprehensive care plan to attain or maintain the highest practicable physical, mental, and psychosocial well-being for 1 of 3 residents (R3) reviewed for behavior management. R3's son passed away and R3 experiences on going grief and sadness. R3 receives behavioral health services, but interventions and recommendations have not been care planned. R3 shared she has past trauma, and this has not been care planned to ensure all staff are aware and offer appropriate interventions and support. Evidenced by: [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure residents are free of significant medication errors, for 1 of 4 residents reviewed in the medication administration task (R32). Surveyor observed RN J (Registered Nurse) crush R32's Levetiracetam ER (Extended Release) (an anticonvulsant medication used to prevent and control seizures for people with epilepsy) and prepare to administer it to R32. Evidenced by: The facility policy, Medication Administration, dated 2/2025, states in part: Policy: Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection .10. Ensure that the six rights of medication administration are followed: a. Right resident b. Right drug c. [...]

Inspectors wroteBased on interview and record review the facility did not ensure hospice collaboration and communication processes were established to ensure continuity of care between hospice and the facility for 2 of 2 residents (R31 and R41) reviewed for hospice. R31's current hospice plan of care was not available to facility staff. R41's current hospice plan of care was not available to facility staff. This is evidenced by: The facility's Coordination of Hospice Services policy, dated 2/2025, states, in part: When a resident chooses to receive hospice care and services, the facility will coordinate and provide care in cooperation with hospice staff in order to promote the resident's highest practicable physical, mental, and psychosocial well-being.2. The facility and hospice provider will coordinate a plan of care . 4. [...]

Inspectors wroteBased on interview and record review, the facility did not 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 infection. This has the potential to affect all 48 residents who reside at the facility. The facility is not monitoring the temperature of their water heater or hot water storage tank as part of their control measures per their Water Management Program. This is evidenced by: The facility's infection Prevention and Control Program policy, dated 2/25, states, in part: Policy: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure other alternatives were tried prior to installing/utilizing side rails. The facility failed to identify and recognize that the use of side rails with an air mattress increases the risk for entrapment for 12 of 12 residents in the facility (R1, R2, R3, R4, R5, R6, R7, R8, R9, R10, R11, R12) who use a side rail and an air mattress. On 9/23/22, the facility implemented the use of a side rail for R1. The facility failed to ensure other alternatives were tried prior to installing/utilizing side rails/enabler device for R1. On 1/8/24, the facility changed R1's mattress to a Panacea Convertible Mattress with powered alternating-pressure therapy (a pump); the facility failed to complete an assessment for entrapment at this time. [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not implement professional standards of practice to ensure that a resident did not develop a pressure injury (PI) and that the resident received necessary treatment and services to promote healing and prevent infection of the pressure injury for 1 of 4 residents sampled for pressure injuries (R2). R2 had a history of pressure injuries and was at risk for PI development. The facility failed to implement aggressive measures upon admission, failed to update R2's MD timely when a new pressure injury developed, failed to re-evaluate interventions that were not working, failed to update the care plan timely, failed to complete diabetic foot checks per current standards of practice, and failed to use R2's offloading boots per manufacturer's guidelines. [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure that 5 (R23, R3, R33, R20, R34) of 5 residents reviewed for restraints were free from physical restraints out of a total sample of 19 residents. -Staff physically held down R23's one good hand during the altercation. The facility failed to identify this act as a physical restraint. R3 had a seatbelt she could not remove on demand. The facility did not consider this device a restraint and did not have an appropriate medical symptom for the restraint use. R20 voiced concerns regarding her seatbelt and was unsuccessful in removing her seatbelt on command. The facility did not consider this device a restraint. R33 and R34 were unable to remove seatbelt on command. The facility did not consider this device a restraint. Evidenced by: State Operations Manual Appendix PP, states, in part under F604: [...]

Inspectors wroteBased on observation, interview, and record review the facility did not promote and facilitate resident self-determination through support of resident choice for 1 of 2 residents (R20) out of a total sample of 19. R20 asked to lie down after breakfast three days and staff told her she needed to wait. Example 1 R20 was admitted to the facility on [DATE]. Her most recent Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 1/12/23, indicates R20's cognition is mildly impaired with a Brief Interview for Mental Status (BIMS) score of 9 out 15. On 2/15/23 at 10:15 AM R20 stated, I want to lie down. They never help me. They tell me I have to wait until after lunch. I need to lie down. I am exhausted. On 2/15/23 at 10:16 AM Surveyor informed CNA R (Certified Nursing Assistant) that R20 was asking to lie down. CNA R stated, She will be going to lunch soon. [...]

Inspectors wroteBased on interview and record review the facility did not ensure to consult with the resident's physician when there is a significant change in the residents physical, mental,or psychosocial status for 2 of 19 sampled residents (R22 and R46). R22 experienced a 7.83% weight loss between 11/4/22-1/4/23, R22's physician was not consulted. R46 experienced a 17.4 pound weight gain in one month and staff did not notify R46's Medical Doctor (MD) of this significant weight gain. This is evidenced by the following: The Facilities Policy and Procedure entitled Weight Monitoring Guideline dated 11/2020, documents, in part: I. POLICY: It is the practice of the facility to weigh residents upon admission and monthly to ensure appropriate clinical care .4. If there is a weight loss of 5% or more in one month or 10% or more in 6 months, the physician is updated . [...]

Inspectors wroteBased on observation and interview, the facility did not maintain personal privacy for 1 of 1 resident (R20) reviewed for privacy out of a total sample of 16. R20 voiced concerns regarding the open spaces in the privacy curtain between her and her roommate. Surveyor and R20 reported this to staff who did not follow up on R20's concern. Evidenced by: R20 was admitted to the facility on [DATE]. Her most recent MDS (Minimum Data Set) with ARD (Assessment Reference Date) of 1/12/23, indicates R20's cognition is mildly impaired with a BIMS (Brief Interview for Mental Status) score of 9 out 15. On 2/16/23 at 8:40 AM R20 indicated she had a concern with her privacy curtain. R20 pointed to the curtain as it was pulled to separate the two sides of the room and indicated the curtain gets hung up on the footboard of her bed causing a gap. Surveyor observed the gap in the curtain. [...]

Inspectors wroteBased interview and record review the facility did not ensure that a resident with limited range of motion receives appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion for 1 of 3 residents (R10) reviewed for limited range of motion (ROM) of 19 sampled residents. R10 is not receiving her restorative care per written program. This is evidenced by: The Facilities Policy and Procedure entitled Restorative Nursing Program dated 4/18/2016, documents, in part: [...]

Inspectors wroteBased on interviews and record review, the facility failed to ensure antibiotics were not used for an excessive duration and without adequate monitoring for 1 of 6 residents (R213) reviewed for unnecessary medications in a total sample of 19 residents. R213 was prescribed an antibiotic without meeting criteria for a Urinary Tract Infection (UTI).