Jackson Gardens Health and Rehabilitation Center

Inspectors wroteBased on observations, interviews and records reviewed, the facility failed to maintain an environment free of accident hazards in two (fourth floor and second floor) out of three air conditioning unit rooms which could be locked from the inside and were found unlocked, presenting a risk that residents might enter and become trapped. There were 111 residents residing in the facility at the time of survey.

Inspectors wroteBased on observations, records reviewed and interviews, the facility did not store medications and biologics correctly on two out of three medication carts (fourth floor carts 1 and 2) and in one out of two medication rooms (second floor medication room) selected for checking medication labeling and storage. Expired, unlabeled, and mislabeled eye drops and insulins were found in fourth floor medication carts 1 and 2. The refrigerator in the second-floor medication room was above the recommended temperature for storing medications. At the time of the survey, the facility had six medication carts and three medication rooms.

Inspectors wroteBased on observations, record review and interviews, the facility failed to accommodate a resident's choice for food preferences for one resident (Resident number 22) out of one resident reviewed for choices and preferences. There were a total of 111 residents residing in the facility at the time of this survey.

Inspectors wroteBased on observations, records reviewed and interviews facility staff did not properly position indwelling catheter tubing for two residents (Resident #79 and Resident #86) out of two sampled residents with indwelling urinary catheters. The indwelling urinary catheter tubing for Resident #79 and Resident #86 formed circular loops, which prevented urine from flowing freely and increased the risk for catheter-associated urinary tract infections and other serious medical issues. Seven residents with indwelling urinary catheters lived in the facility at the time of the survey.

Inspectors wroteBased on observations, record reviews, and interviews, facility staff did not consistently implement infection prevention and control procedures for one (Resident #81) out of three sampled residents receiving oxygen and for two (Residents #79 and Resident #8) out of three sampled residents out of the thirty-three residents with orders for Enhanced Barrier Precautions, as evidenced by: 1)The humidifier for Resident #81 had not been replaced in over seven days. 2) Facility staff did not properly dispose of biohazardous material after Resident #79's dressing change. 3) Staff did not adhere to Enhanced Barrier Precautions by failing to wear required Personal Protective Equipment when providing hygiene care and linen changes for Resident #8. These deficient practices increased the risk of infections and disease spreading. [...]

Inspectors wroteBased on observations, interviews and record review the facility failed to ensure infection control standards were followed for two Residents (Resident #101 and Resident #92) out of two of the nine sampled residents as evidenced by observations a tube feeding syringe not labeled, a staff member not wearing a gown while providing hygiene care for a resident receiving tube feeding and an observation of no sign posted for Enhanced Barrier Precaution (EBP) for a Resident with an IV (intravenous)site. There were 122 residents residing in facility at the time of survey.

Inspectors wroteBased on observations, interviews, and record review the facility failed to provide privacy for the health care information for residents as evidenced by observations of three computer screens open with resident information visible while unattended on the fourth floor. There were 112 residents residing in the facility at the time of survey.

Inspectors wroteBased on observations, interviews and record review the facility failed to provide an environment free from potential safety hazards for one resident (Resident #79) out of nine residents sampled as evidenced by an observation of a shaving razor on the top of the light fixture and bed control with exposed wires next to the resident who was in bed asleep. The findings Included: On 9/23/24 at 9:28 AM Resident#79 was observed in bed with eyes closed. The bed control with exposed wires was observed on the bed next to Resident #79. A blue shaving razor was observed on the top of the light fixture above Resident#79. (photo evidence) On 9/23/24 at 9:33 AM, Staff J, Registered Nurse (RN) was notified, and the razor was removed and placed the trash in a clear plastic bag. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to be free from significant medication error for one Resident (Resident # 5) out of nine sampled as evidenced by during observation of medication administration Nifedipine Extended-Release tablet was crushed by the Registered Nurse. There were 112 residents residing in the facility at the time of survey.

Inspectors wroteBased on observations, interviews and record review the facility failed to store medications properly as evidenced by two medication carts on the floor out of the six medication carts in the facility were observed unlocked and unattended. The findings Included: On 09/24/24 at 4:45 PM, a medication administration observation was completed with Staff A, Registered Nurse (RN) on the fourth-floor medication cart two. Staff A, (RN) left the cart open, knocked on the resident's door; surveyor asked what the facility's protocol for securing medication in medication carts is. Staff A, RN replied, I left the cart unlocked because I am nervous. Whenever I leave the medication cart I am supposed to lock it. The purpose of locking the cart is for the safety of residents. On 9/25/24 at 5:50 AM; [...]

Inspectors wroteBased on record reviews and interviews the facility failed to demonstrate effective plan of actions were implemented to correct identified quality deficiency in the problem area related to repeated deficient practice for F880-Infection Prevention and Control. As evidenced by staff observed not wearing correct PPE during care of residents on Enhanced Barrier Precautions (EBP) and an enteral feeding syringe not labeled during observations on a recertification survey ending 09/26/24. There were 112 residents residing in the facility at the time of survey.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure infection control practices related to hand hygiene was implemented during dining observations. As evidenced by staff failure to sanitize hands between the passing of meal trays. This deficient practice has the potential to cause cross contamination and affect all residents in the facility. There were 106 residents residing in the facility at the time of this survey.