Jefferson Manor Nursing and Rehab Ctr, LLC

Inspectors wroteBased on interviews and record reviews, after transfer to an acute care facility, the facility failed to allow a resident to return to the facility where the resident had lived for years saying he was a safety risk to others for 1 (#1) of 3 residents. Review of the resident's records did not show the resident had any new needs after hospitalization that could not be met by the facility. As a result, the resident was transferred from the hospital to a different nursing home. Resident # 1 Record review revealed Resident #1 was admitted to the facility on [DATE] with diagnoses ofDementia, Paranoid Schizophrenia, and Bipolar Disorder. Further review of the clinical record revealed no documented evidence of behavioral issues or physical altercations from 07/05/2024 to 04/15/2026. Review of the April 2026 Physician's Orders for Resident #1 revealed the following treatments: [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to prepare food to conserve flavor and appearance and provide palatable and attractive food for 8 (#2, #9, #12, #36, #41, #43, #68 and #91) of 8 residents reviewed for dining. There were 92 residents who ate from the facility's kitchen.

Inspectors wroteBased on interviews and record review, the facility failed to accurately code PASRR Level IIs on the residents' MDS assessments for 2 (#8 and #25) of 3 residents reviewed with Level II PASRRs.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain good grooming and hygiene by failing to provide incontinence care timely for 1 of 1 (#5) resident reviewed for activities of daily living in the final sample. Review of the facility's undated policy titled, Incontinent care: Bladder revealed in part, the following: Perineal management is the cleansing of the perineal area that includes the genitalia and rectal areas. It promotes cleanliness and comfort and prevents infection by removing irritating secretions or excretions, microorganisms, and offensive odors. The care should be administered daily during bathing, and more frequently following urinary and/or fecal incontinence or if excessive secretions are present. [...]

Inspectors wroteBased on observation, interviews, and record review, the facility failed to store food in accordance with professional standards for food service safety by failing to refrigerate opened food items and label and date opened frozen food items. There were 92 residents who received food from the facility's kitchen.

Inspectors wroteBased on observation and interviews, the facility failed to maintain a clean, comfortable and homelike environment for 1 (#1) of 6 (#1, #2, #3, R7, R8, and R9) residents reviewed for environment.

Inspectors wroteBased on record review and interviews, the facility failed to ensure Minimum Data Set (MDS) assessments were completed and transmitted timely for 1 (#2) of 3 (#1, #2, and #3) sampled residents reviewed for resident assessment.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to: 1. Ensure nurse staffing data requirements were documented on daily postings, and 2. Ensure nurse staffing data was posted daily in a prominent location readily accessible to residents and visitors. This deficient practice had the potential to affect any of the 97 residents residing in the facility.

Inspectors wroteBased on record review, video observation, and interviews the facility failed to ensure the residents' right to be free from neglect for all residents who resided on Hall A (Rooms 1-30). Nursing staff neglected to respond to call lights and provide any care and services to all resident's residing on Hall A from 11:00 p.m. to 2:30 a.m. on the night of [DATE]. As a result of the identified noncompliance, serious harm, serious impairment, death, or psychosocial harm was likely to occur to the residents residing on Hall A. This deficient practice resulted in an Immediate Jeopardy (IJ) situation on [DATE] at approximately 11:00 p.m. when Resident #1, who had a physician's order for staff to visually check the resident every 2 hours, activated her call light for staff assistance. No staff responded to her call until approximately 2:39 a.m. [...]

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure residents were assessed for risk of entrapment from bedrails and informed consents were obtained prior to installation of bedrails for 4 (#1, #3, #R1, and #R2) of 4 sampled residents identified for having bedrails in use. This deficient practice had the potential to affect all 51 residents residing in the facility with bedrails in use.

Inspectors wroteBased on video observation, interviews and record review, the facility failed to ensure alleged violations involving neglect were reported to the state agency within 2 hours after the allegations of neglect were made for Resident #1, Resident #3, and all other residents residing all Hall A.

Inspectors wroteBased on interviews and record review, the facility failed to ensure residents' assessments accurately reflected the residents' status by failing to ensure the Minimum Data Set (MDS) was accurately coded for PASRR (Preadmission Screening and Resident Review) for 1 of 1 (#99 ) resident reviewed for PASRR.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to provide necessary care and services for the provision of respiratory care in accordance with professional standards for 1 (#56) of 3 (#52, #56, #80) residents reviewed for respiratory services. The facility failed to ensure Resident #56's oxygen tubing and humidifier bottle were properly labeled.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure a resident with Post Traumatic Stress Disorder (PTSD) received trauma-informed care and services in accordance with professional standards of practice for 1 of 1 (#93) resident residing in the facility with PTSD. The facility failed to assess and develop a plan of care for Resident #93's history of trauma.

Inspectors wroteBased on observation, interviews and record review, the facility failed to ensure medications were administered to meet the needs of each resident by failing to ensure orders were accurately transcribed for 1 of 1 (#49) residents reviewed for pressure ulcers.

Inspectors wroteBased on observations, record reviews, and interviews, the facility failed to ensure a resident received the correct food portions as ordered by a physician for 1 (#13) of 2 (#13 and #90) sampled residents reviewed for dietary services.

Inspectors wroteBased on record reviews and interviews, the facility failed to maintain accurate documentation of the route of medication administration for 1 of 1 (#49) residents reviewed for pressure ulcers.

Inspectors wroteBased on record review, video observation, and interviews the facility failed to ensure residents received adequate supervision to prevent elopement from the facility for 1 (#1) of 5 (#1, #2, #3, R1 and R2) sampled residents reviewed for elopement. This deficient practice resulted in an Immediate Jeopardy (IJ) situation on 12/14/2024 at 4:32 a.m. when Resident #1, a moderately cognitively impaired resident with a physician's order for staff to visually check the resident every 2 hours, eloped from the facility. On 12/14/2024, staff last visualized Resident #1 at approximately 4:00 a.m. Resident #1 was observed on video footage eloping from the facility by climbing over the patio fence at 4:32 a.m., without staff knowledge. Facility staff had not realized Resident #1 eloped from the facility until approximately 8:00 a.m. [...]

Inspectors wroteBased on record review and interviews, the facility failed to ensure an allegation of neglect was reported to the State Survey Agency in the required timeframe for 1 (#1) of 5 (#1, #2, #3, #R1 and R2) sampled residents reviewed for elopement.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to provide privacy to residents when receiving assistance with personal care for 3 (#2, #R1 and #R5) of 5 (#2, #3, #R1, #R3, and #R5) residents observed during Activities of Daily Living. The facility failed to ensure: 1. Privacy curtains were pulled and the room door was closed prior to staff providing incontinence care to Resident #2 and Resident #R1; and 2. Resident #R5 had privacy curtains around his bed and were pulled prior to staff providing incontinence care.

Inspectors wroteBased on observations, interviews and record reviews the facility failed to ensure a resident who was unable to carry out Activities of Daily Living (ADL's) received the necessary services to maintain good hygiene for 3 (#2, #R1, and #R3) of 6 (#1, #2, #3, #R1, #R3, and #R5) residents reviewed for ADL's. The facility failed to ensure: 1. Resident #2 and Resident #R1 received incontinence care timely; and 2. Resident #2 and #R3 received oral care daily.

Inspectors wroteBased on observations, interviews and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe and sanitary environment to help prevent the development and transmission of infection for 4 (#2, #3, #R1 and #R3) of 9 (#1, #2, #3, #R1, #R2, #R3, #R4, #R5, and #R6) resident's reviewed in the sample. The facility failed to ensure: 1. Staff wore proper Personal Protective Equipment (PPE) while providing care to Resident #3 and Resident #R3, who were on Enhanced Barrier Precautions (EBP); and 2. Staff performed appropriate infection control practices, hand hygiene, and proper glove use for Resident #2 and Resident #R1 observed for incontinence care.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to ensure residents received care, consistent with professional standards of practice, to prevent pressure ulcers. This deficient practice was evidenced by failing to ensure a resident with orders for heel protectors failed to have pressure reducing interventions implemented per Physician's Orders for 1 (#2) of 9 (#1, #2, #3, #R1, #R2, #R3, #R4, #R5, and #R6) sampled residents.

Inspectors wroteBased on record review, observation and interviews, the facility failed to maintain accurate records in accordance with accepted professional standards and practices for 1 (#3) of 3 (#1, #2, and #3) sampled residents. The facility failed to ensure nursing staff accurately documented Resident #3's bowel movements.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure a resident's significant change in status was reported to the physician for 1 (#1) of 3 (#1, #2 and #3) sampled residents reviewed for notification of change. This deficient practice resulted in an Immediate Jeopardy situation on [DATE] at approximately 1:12 p.m. for Resident #1, a resident requiring mechanical lift with 2 person assistance for transfers, when S8CNA transferred the resident without another staff member's assistance. The transfer resulted in Resident #1 falling from the lift to the floor. On [DATE] from 1:48 p.m. to 1:53p.m., Resident #1 told S5CNA, S6CNA and S7CNA, I am going to die and showed symptoms of increased anxiety. None of the CNAs reported this to the nurse. Resident #1 was found unresponsive at 1:55 p.m., CPR initiated, and transferred to the hospital via emergency transportation. [...]

Inspectors wroteBased on record reviews and interviews, the facility failed to ensure residents, who required two person assistance with mechanical lift transfers, remained free of accident hazards for 1 (#1) of 8 (#1, #2, #3, R1, R2, R3, R4, and R5) residents reviewed for transfers. This deficient practice resulted in an Immediate Jeopardy situation on [DATE] at approximately 1:12 p.m. for Resident #1, a resident requiring mechanical lift with 2 person assistance for transfers, when S8CNA transferred the resident without another staff member's assistance. The transfer resulted in Resident #1 falling from the lift to the floor. Resident #1 was found unresponsive at 1:45 p.m., CPR initiated, and transferred to the hospital via emergency transportation. Resident #1 expired in the hospital at 2:24 p.m. from cardiac arrest. [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure an allegation of neglect resulting in serious bodily injury was reported immediately, but no later than two hours to the facility Administrator and to the State Survey Agency for 2 (#1 and #2) of 3 (#1, #2, and #3) residents sampled for allegations of neglect.

Inspectors wroteBased on record review and interviews, the facility failed to implement a comprehensive person-centered care plan for 1 (#2) of 3 (#1, #2 and #3) residents reviewed in the sample. The facility failed to ensure Resident #2 was transferred properly using the mechanical lift with two person assistance.

Inspectors wroteBased on record reviews and interview, the facility failed to transmit MDS assessments in the required timeframe for 2 (#49 and #80) of 2 (#49 and #80) residents reviewed for Resident Assessment.

Inspectors wroteBased on interviews and record review, the facility failed to implement a comprehensive person centered care plan to meet a resident's needs for 1 (#11) of 3 (#3, #11 and #89) residents reviewed for ADL care. The facility failed to ensure Resident #11 received a Chlorhexidine Gluconate bed bath twice a week as ordered by the Physician.

Inspectors wroteBased on interviews and record review, the facility failed to ensure services were provided to meet quality professional standards for 1 (#11) of 3 (#3, #11 and #89) residents reviewed. The facility failed to accurately document Resident #11's Chlorhexidine Gluconate bed bath had been performed per Physician's Order.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain personal hygiene for 1 (#11) of 3 (#3, #11 and #89) residents reviewed for ADLs.

Inspectors wroteBased on observations, record review, and interviews, the facility failed to implement 1 (#2) of 3 (#1, #2, #3) sampled resident's care plan interventions by failing to perform placement of a right hand splint.

Inspectors wroteBased on interviews and record reviews, the facility failed to protect the residents' right to be free from verbal abuse by S11CNA for 1 (#1) of 3 (#1, #2, and #3) residents reviewed for abuse. The facility implemented corrective actions which were completed prior to the State Agency's investigation, thus it was determined to be a Past Noncompliance Citation.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure verbal abuse was reported to the facility administrator immediately, but not later than 2 hours after abuse occurred for 1 (#1) of 3 (#1, #2, and #3) residents reviewed for abuse. This was evidenced by S12CNA failing to notify administration immediately after S11CNA was witnessed verbally abusing Resident #1. The facility implemented corrective actions which were completed prior to the State Agency's investigation, thus it was determined to be a Past Noncompliance Citation.