Jefferson House

Inspectors wroteBased on staff interview and review of Payroll Based Journal (PBJ) submissions for Quarter 1 (October 1, 2024 through December 31, 2024) and Quarter 2 (January 1, 2024 through March 31, 2024) the facility failed to ensure the PBJ data was submitted on time.

Inspectors wroteBased on observations, review of the clinical record, facility documentation, facility policy and interviews for 1 of 4 sampled residents, (Resident #57) reviewed for accidents, the facility failed to implement a physician's order for the application of padded side rails. Additionally, for 1 of 1 sampled resident (Resident #63) reviewed for choices, the facility failed to schedule an appointment with a specialist per provider recommendations and resident request, and for 1 of 3 residents (Resident #87) reviewed for general concerns, the facility failed to schedule a hematology consult per physician's order.

Inspectors wroteBased on the tour of the Dietary Department, interviews, review of facility policy and facility documentation, the facility failed to ensure that beard restraints were worn appropriately, perform hand hygiene when appropriate, ensure open food items were properly closed/dated and not near debris on the floor and failed to discard expired food items.

Inspectors wroteBased on observations, review of the clinical record, facility policy, and staff interviews for 5 of 5 residents (Resident #10, #32, #66, #73, and #83) reviewed for blood glucose testing, the facility failed to clean and disinfect a glucometer device per the manufacturer's instructions for use. 1. Resident #10's diagnoses included Type 2 Diabetes, Alzheimer's disease, and chronic obstructive pulmonary disease (COPD). A physician's order dated [DATE] directed to obtain a blood glucose level every Tuesday at 6:00 AM. A chart review identified that Resident #10 had blood glucose checks performed per physician order on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. [...]

Inspectors wroteBased on observation, review of the clinical record, facility documentation, facility policy and interviews for 2 of 3 residents (Resident #87 and Resident #353) reviewed for transmission-based precautions, the facility failed to ensure privacy related to having the posted isolation sign identify the type of infection/reason for the resident's isolation.

Inspectors wroteBased on observations, review of clinical records, facility documentation, facility policy and interviews for 2 of 5 residents (Resident #9 and Resident #64) reviewed for unnecessary medications, the facility failed to follow professional standards for medication administration.

Inspectors wroteBased on clinical record reviews, review of the Resident Assessment Instrument (RAI) Manual, facility policy, and interviews for 2 of 4 sampled residents (Resident #49 and Resident #89) reviewed for resident assessment, the facility failed to complete a Quarterly Minimum Data Set (MDS) assessment in a timely manner.

Inspectors wroteBased on record review, staff interview and Resident Assessment Instrument (RAI) policy for 4 of 4 sampled residents (Resident's #49, #52, #89, and #96) reviewed for late Minimum Data Set (MDS) transmittals, the facility failed to ensure MDS' were transmitted timely.

Inspectors wroteBased on tour of the nourishment rooms and interviews, the facility failed to ensure that 3 sinks in 4 nourishment rooms were maintained in a clean and sanitary manner.

Inspectors wroteBased on clinical record review, facility documentation review, facility policy review, and interviews for one of three residents (Resident #1) reviewed for abuse, the facility failed to ensure the resident was free from mistreatment.

Inspectors wroteBased on a tour of the kitchen and staff interview, the facility failed to ensure that kitchen equipment was maintained in a sanitary manner.

Inspectors wroteBased on clinical record reviews, observations, facility policy review and interviews for for four residents (Resident #19, #29, #52 and #77) requiring assistance to eat in 2 of 4 dining rooms, the facility failed to provide a dignified dining experience.

Inspectors wroteBased on review of the clinical record, facility documentation, facility policy and interviews for 2 of 2 sampled residents (Resident #1 and Resident #22), the facility failed to ensure advanced directives in the paper clinical record matched advanced directives in the electronic health record (EHR).

Inspectors wroteBased on observation, review of facility documentation, staff interviews, and facility policy, the facility failed to ensure the environment was maintained in good repair and a homelike manner.

Inspectors wroteBased on review of clinical record and interviews for resident 1 of 1 (Resident #72) reviewed for care planning, the facility failed to ensure that the resident's had an admission baseline care plan.

Inspectors wroteBased on observation, clinical record review and interview for 1 of 3 residents with dentures (Resident #57), the facility failed to revise the plan of care to meet the resident's dental needs.

Inspectors wroteBased on review of the clinical record, facility documentation, facility policy, and interviews for 2 of 2 residents (Resident #31 and Resident #87) reviewed for care planning, the facility failed to revise and update the resident's care plan according to timely.

Inspectors wroteBased on observations, clinical record review and staff interviews for 2 of 3 residents reviewed during dining (Residents #8 and #29), the facility failed to ensure supervision during group dining to prevent a potential accident.

Inspectors wroteBased on observations, clinical record review, facility policy review, and interviews for 1 of 4 medication carts on the first floor, the facility failed to ensure medications were stored in a secure manner.

Inspectors wroteBased on observations, facility documentation review, facility policy review, and interviews for kitchen review, the facility failed to ensure the walk-in refrigerator was maintained at the appropriate temperature, and the facility failed to ensure high refrigerator temperatures were rechecked for accuracy and recorded any repeat temperature checks.

Inspectors wroteBased on clinical record review, facility documentation review and interviews for one sampled resident reviewed for abuse (Resident #43), the facility failed to ensure the resident received assistance in a dignified manner.

Inspectors wroteBased on observations, clinical record review, facility policy review, and interviews for one of three residents reviewed for abuse, (Resident #4), the facility failed to ensure staff consistently implemented the facility policy for abuse and the facility failed to ensure staff reported an allegation of mistreatment timely.

Inspectors wroteBased on observations, clinical record review, facility documentation review, and interviews for one of four residents, (Resident #17), reviewed for pressure ulcers, the facility failed to ensure a dressing order was in place prior to use, and failed to ensure appropriate monitoring of skin covered by a dressing, and failed to ensure a dressing was changed regularly.

Inspectors wroteBased on observations, clinical record review, facility documentation review, and interviews for one of two residents (Resident #17) reviewed for accidents, the facility failed to implement the plan of care related to fall prevention.

Inspectors wroteBased on observations, interview and review of facility policy, for medication storage review, the facility failed to ensure that all Intravenous (IV) solutions and supplies were removed from the emergency supply timely when expired.