Jackson Manor

Inspectors wroteBased on interview and record review, the facility failed to notify the resident and/or the resident's representative in writing of a transfer or discharge to a hospital, including the bed hold rate and reason for transfer for four residents (Residents #14, #16, #53, and #85) out of six sampled residents. The facility's census was 66. Review of the facility's policy titled, Discharge/Transfer - Involuntary, dated 10/07/21, showed: - The facility must provide a written notice to the resident, and if known, a family member or legal representative of the resident prior to the resident being transferred or discharged ; - The written discharge notice must contain the reason for transfer or discharge, the date of transfer, and the location to which the resident is transferred or discharged . Review of the facility's policy titled, Resident Bed Hold, dated 11/15/22, showed: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to obtain and follow physician's orders for four residents (Residents #1, #5, #49, and #56) out of 17 sampled residents. The facility census was 66. Review of the facility policy titled, Physician Orders, last reviewed 09/28/22, showed: - Physician orders shall be provided by Licensed Practitioners (Physicians, Nurse Practitioners and Physician's Assistants) authorized to prescribe orders; - Orders must be recorded in the medical record by the Licensed Nurse authorized to transcribe such orders; - Physician orders must be documented clearly in the Medical Record. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to provide necessary services to maintain grooming, and personal hygiene for two residents (Residents #53 and #85) out of eight sampled residents. The facility census was 66. Review of the facility's policy titled, Activities of Daily Living (ADL) Care Bathing, dated 07/21/22, showed:- Nursing staff will assist in bathing residents to promote cleanliness and dignity;- The policy did not address how often showers will be given. Review of Resident Shower Schedule, undated, showed:- Resident #53 scheduled for showers two times weekly on Tuesday and Friday;- Resident #85 scheduled for showers two times weekly on Wednesday and Saturday. 1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to change and date the oxygen tubing (a flexible tube that connects to the oxygen concentrator and delivers supplemental oxygen through the nostrils) and the humidifier bottle per physician orders. This practice affected one resident (Resident #14) out of two sampled residents. The facility census was 66. Facility did not provide a policy regarding oxygen tubing and humidification. 1. Review of Resident #14's medical record showed: - admission date of 04/16/24; - Diagnoses of chronic respiratory failure with hypoxia, dependence on supplemental oxygen; - An order to change oxygen tubing and storage bag weekly one time a day every Sunday, dated 11/24/24; - An order for oxygen at three liters continuous via nasal cannula, dated 11/01/24; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain proper infection control practices when providing gastrostomy tube (g-tube - a feeding tube inserted into the stomach to provide nutrition, fluids, and medication) care for one resident (Resident #49) out of three sampled residents, when providing blood sugar checks for one resident (Resident #14) out of three sampled residents, when providing insulin to two residents (Residents #14 and #69) out of three sampled residents, and for catheter (a tube inserted into the bladder to drain urine) drainage bag care for one resident (Resident #1) out of one sampled resident. The facility census was 66. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide palatable, attractive food at a safe and appetizing temperatures for eight residents (Resident #1, #,3, #4, #5, #6, #8, #9, #10) out of 10 sampled residents. This deficient practice had the potential to affect all residents in the facility. The facility's census was 68. The facility did not provide a food temperature policy. Review of the facility's Resident Council minutes, dated 09/12/24, showed eight residents said the food was always cold for both the dining room and the hall trays. Observations of the evening meal on 09/19/24, showed at 6:34 P.M., staff delivered Resident #1's room tray to his/her room. The temperature of the hamburger measured 94 degrees Fahrenheit (F) and the potato wedges measured 96 degrees F. During an interview on 09/19/24 at 4:20 P.M., Resident #8 said the food was always cold. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe, clean, comfortable, and homelike environment. This deficient practice affected one resident (Resident #35) out of 17 sampled residents, one resident (Resident #48) outside the sample, and had the potential to affect all residents in the facility. The facility's census was 68. The facility did not provide a policy regarding the environment. 1. Observation on 07/08/24 at 2:35 P.M. of room [ROOM NUMBER] showed: - Four dime-sized brown stains and a long brown stain approximately four inches long on the divider curtain; - Scrapes and scratches on the bathroom door and trim; - Veneer missing from the sink vanity; - Scrapes on the drawers of the sink vanity; - Veneer missing on the closet door; - Scrapes on the closet door; [...]

Inspectors wroteBased on interview and record review, the facility failed to notify the resident and/or the resident's representative in writing of a transfer to hospital, including the reason for transfer, and failed to notify the Office of the State Long-Term Care Ombudsman for two residents (Resident #2 and Resident #58) out of 17 sampled residents. The facility's census was 68. The facility did not provide a policy. 1. Review of Resident #2's medical record showed: - Transferred to the hospital on [DATE], and readmitted to the facility on [DATE]; - No documentation that the resident or resident's responsible party had been notified in writing; - No documentation of transfer/discharge notice given to the Ombudsman. 2. Review of Resident #58's medical record showed: - Transferred to the hospital on [DATE], and readmitted to the facility on [DATE]; [...]

Inspectors wroteBased on interview and record review, the facility failed to inform the resident and/or resident's representative, in writing, of the facility's bed hold policy at the time of transfer to the hospital for two residents (Resident #2 and Resident #58) out of 17 sampled residents. The facility's census was 68. Review of the facility's Bed Hold policy, last reviewed 11/15/22, showed: - The facility will provide written information to the Resident and/or Resident's Representative regarding the Bed Hold Policy, prior to transferring a Resident to the hospital, as required by State/Federal Guidelines; - The facility will have policies that address holding the Resident's bed during periods of absence; - The facility will provide written information about these policies to Residents/Resident's Representatives prior to and upon transfer. 1. Review of Resident #2's medical record showed: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide showers for three residents (Resident #2, #18, and #21) out of 17 sampled residents and one resident (Resident #4) outside the sample. The facility's census was 68. Review of the facility's policy, ADL Care Bathing, dated 07/21/22, showed: - Nursing staff will assist in bathing to promote cleanliness and dignity; - The charge nurse will be made aware of residents who refuse bathing. 1. Review of Resident #2's medical record showed: - Diagnosis of quadriplegia (a form of paralysis that affects all four limbs, plus the torso); - Scheduled shower days on Monday and Thursday. Review of the resident's annual Minimum Data Set (MDS - a federally mandated assessment completed by the facility staff), dated 01/05/24, showed: - Cognitive status intact; - Dependent on staff for dressing; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain proper infection control practices to prevent transmission of infection during insulin administration for one resident (Resident #68) out of 17 sampled residents and while providing incontinent care for one resident (Resident #52) outside the sample. The facility also failed to provide appropriate documentation of tuberculosis (TB-an infectious bacterial disease that affects the lungs) testing for three residents (Residents #24, #30 and #42) out of five sampled residents. The facility's census was 68. Review of the facility's policy, Hand Hygiene, last reviewed 04/28/22, showed: - Hand hygiene should be performed before and after providing care; - After contact with blood, body fluids or contaminated surfaces; - Before and after applying or removing gloves or Personal Protective Equipment (PPE); [...]

Inspectors wroteBased on observation and interview, the facility failed to post the nurse staffing data in a clear and readable format in a prominent place readily accessible to residents and visitors on a daily basis at the beginning of each shift. The facility's census was 68. The facility did not provide a policy for posting nurse staffing data. Observations on 07/08/24, 07/09/24, 07/10/24 and 07/11/24 showed the facility did not post the nurse staffing data. The last posted nurse staffing data sheet was dated 06/28/24. During an interview on 07/11/24 at 8:30 A.M., the Assistant Director of Nurses (ADON) said the Director of Nurses (DON) fills out the daily staffing sheets, but he/she is not in the area this week, and hasn't been in the facility all week. The ADON stated that he/she is covering for the DON while he/she is out. [...]

Inspectors wroteBased on interview and record review, the facility failed to maintain quarterly Quality Assurance and Improvement Program (QAPI) committee meetings with the required members. The facility's census was 68. Review of the facility's policy, QAPI, dated 08/20/20, showed: - The Quality Assessment and Assurance (QAA) committee will meet monthly to assess and monitor the quality of services provided to residents and identify potential problems or areas of opportunity for improvement; - Team Members: Administrator, Director of Nursing, Medical Director/Designee, Infection Preventionist, Social Services Designee, Activities Director, Environmental Services, Dietary Manager/Designee, Medical Records, Human Resources and Pharmacy. Review of the QAPI sign in sheets, provided by the Administrator, showed the Medical Director did not attend any meetings from April 2024 through June 2024. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow acceptable standards of nursing practice by failing to utilize safety needles and failing to properly administer insulin (a hormone that lowers the level of glucose, or sugar, in the blood) for three residents (Resident #31, #33, and #44) outside of the 18 sampled residents. The facility census was 70. Record review of the facility's Standard Precautions policy, dated 10/25/22, showed: - Standard precautions include sharps safety and safe injection practices; - Do not recap, bend, cut, break, or hand manipulate used needles. Record review of the facility's Medication Administration - General Guidelines policy, revised October 2017, showed: - Medications are administered as prescribed in accordance with good nursing principles and practices; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to disinfect the glucometer (a device used to measure blood sugar) per manufacturer's instructions, failed to disinfect the medication cart per facility policy, failed to remove soiled gloves prior to obtaining a new test strip during blood glucose monitoring, and failed to sanitize hands for two sampled residents (Resident #10 and #27) and five residents (Resident #31, #33, #38, #44, and #46) outside the sample. The facility census was 70. Record review of the facility's Medication Administration - General Guidelines policy, revised October 2017, showed: [...]