Jefferson Nursing and Rehabilitation Center

Inspectors wroteBased on interviews and record reviews, the facility failed to provide pharmaceutical services including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of each resident for 1 of 8 (Resident #1) reviewed for pharmacy services. The facility failed to hold Resident #1's blood pressure medication (Midodrine-used to treat severe low blood pressure, particularly orthostatic hypotension, by constricting blood vessels to raise blood pressure) when the blood pressure and/or heart rate was outside the prescribed parameters. This failure could place the residents at risk for adverse consequences and decline in health.

Inspectors wroteBased on observation, interview, and record review the facility failed to store, prepare, distribute, and serve food under sanitary conditions in 1 of 1 preparation kitchen. * The facility did not ensure steam table pans did not have brown colored buildup on the outside edges* The facility did not ensure baking sheets and baking pans did not have brown colored buildup on the outside edges* The facility did not ensure the dish machine was sanitizing the dishes* [NAME] L did not wash hands when entering the kitchen * [NAME] L did not have the beard guard completely covering facial hair These failures could place all residents who eat from the kitchen at risk for foodborne illnesses.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe, sanitary, comfortable and homelike environment for 1 of 18 residents (Resident #47) and 9 of the 22 tables in the dining room reviewed for environment. 1. The facility failed to ensure that Resident #47's dining table was stable and in good repair. 2. The facility failed to ensure the tables in the dining room were in good repair and not wobbly when touched. These failures placed residents at risk of injury, an uncomfortable environment, and a decrease in quality of life and self-worth.

Inspectors wroteBased on observation, interview and record review, the facility failed to 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 infections for 1 of 4 halls. The facility failed to ensure CNA J performed proper hand hygiene while entering and exiting residents' room on hall 300 while providing ice and water for hydration services. The facility failed to ensure CNA D did not touch hydration cart ice scoop to the inside of resident's cup while providing ice and water for hydration services. The facility failed to ensure CNA J and CNA G performed proper hand hygiene and disposal of soiled (dirty) cup while providing ice and water for hydration services. This failure could place residents at risk for the spread of infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents received an accurate assessment, reflective of the resident's status for 1 of 18 residents (Resident # 71) reviewed for accuracy of assessments. The facility did not accurately complete the MDS assessment to indicate Resident #71 received the anticoagulant (blood thinner) medication rivaroxaban. This failure could place the residents at risk of not receiving the appropriate care and services to maintain their highest level of well-being.

Inspectors wroteBased on observation, interview, and record review the facility failed to develop and implement a comprehensive person-centered care plan to meet each resident's medical, nursing, mental, and psychosocial needs for 1 of 18 residents (Resident #71) reviewed for care plans. The facility did not have a care plan to address Resident #71's use of the anticoagulant (blood thinner) medication rivaroxaban. This failure could place residents at risk of not having their individual needs met and not receiving needed services.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents had the right to be free from abuse and neglect for 9 of 22 residents (Resident #2, Resident #3, Resident #4, Resident #9, Resident #13, Resident #19, Resident #20, Resident #25, and Resident #26) reviewed for abuse. 1. The facility failed to ensure Resident #3 was free from physical abuse when Resident #2 and Resident #3 had a physical altercation on 10/23/2024. 2. The facility failed to ensure Resident #3 was free from physical abuse when Resident #4 and Resident #3 was in a physical altercation and Resident #4sustained injuries on 11/09/2024. 3. The facility failed to ensure Resident #4 was free from abuse when Resident #2 wandered into Resident #4's room and both were found on the floor on 11/11/2024. 4. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents received adequate supervision to prevent accidents for 9 of 22 residents (Resident #2, Resident #3, Resident #4, Resident #9, Resident #13, Resident #19, Resident #20, Resident #25, and Resident #26) reviewed for supervision to prevent accidents. 1. The facility failed to ensure Resident #3 was free from physical abuse when Resident #2 and Resident #3 had a physical altercation on 10/23/2024. 2. The facility failed to ensure Resident #3 was free from physical abuse when Resident #4 and Resident #3 was in a physical altercation and Resident #4sustained injuries on 11/09/2024. 3. The facility failed to ensure Resident #4 was free from abuse when Resident #2 wandered into Resident #4's room and both were found on the floor on 11/11/2024. 4. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to implement the written abuse policy to ensure an allegation of physical abuse was reported immediately to the Abuse Coordinator, State Agency, and implement measures to ensure residents were protected from further abuse after an allegation of abuse for 1 of 22 residents (Resident #1) reviewed for allegations of abuse. 1. The facility failed to ensure CNA B was suspended/ terminated or removed from all residents after a physical abuse allegation was reported on 03/11/2025. 2. The facility failed to immediately report the physical abuse allegation to the Abuse Coordinator for Resident #1. The non-compliance was identified as past non-compliance. The Immediate Jeopardy began on 03/11/2025 and ended on 03/17/2025. The facility had corrected the non-compliance before the survey began. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately, but not later than 2 hours after the allegation was made, if the events that caused the allegation involved abuse or result in serious bodily injury, or not later than 24 hours if the events that caused the allegation did not involve abuse and did not result in serious bodily injury, to the State Survey Agency in accordance with State law through established procedures for 2 of 22 residents (Resident #19 and Resident #20) reviewed for reporting allegations of abuse. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure assessments accurately reflected the resident's status for 3 of 25 residents reviewed for assessments. (Residents #1, #36 and #85). The facility failed to complete an accurate resident assessment for Resident #1. Resident #1's resident assessment did not indicate she smoked. The facility did not ensure Resident #36's MDS assessment reflected he was on oxygen. The facility failed to complete an accurate resident assessment for Resident #85. Resident #85's resident assessment did not indicate he was on hospice services. These failures could place residents at risk of not having their individual needs met and a decreased quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide pharmaceutical services including procedures that assure the accurate administering of all drugs to meet the needs of each resident for 1 of 9 residents reviewed for medication administration. (Residents #54) The facility failed to ensure LVN D mixed crushed tablets with 5-10 cc of warm water prior to administering medications to Resident #54's G-tube (Gastrostomy tube-tube surgically inserted through the skin into the stomach) per facility policy. These failures could place residents at risk of not receiving the desired therapeutic effects of their medications and residents with G-tubes at risk of tube clogging/obstruction, medical complications, or a decline in health due to inappropriate G-tube care, management, and not following appropriate procedures.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow their own established smoking policy for 1 of 4 residents (Resident #1) reviewed for smoking. The facility failed to follow their policy on smoking by not completing a smoking safety screen assessment quarterly on Resident #1. This failure could place residents at risk of unsafe smoking and injury.

Inspectors wroteBased on interview and record review, the facility failed to complete a discharge resident assessment within the required time frame for 1 of 25 residents (Resident #39) reviewed for MDS (Minimum Data Set) completion. The facility failed to complete and transmit a required discharge assessment for Resident #39 within 14 days after Resident #39 discharged from the facility. This failure could place residents at risk of not getting continuity of care, if their clinical and discharge assessment information was not current and accurate in the MDS (RAI) database.

Inspectors wroteBased on observation, interview and record review, the facility failed to, in accordance with State and Federal laws, ensure all drugs and biologicals were stored in locked compartments under proper temperature controls, and permitted only authorized personnel to have access to the keys for 1 of 2 nurse medication carts (Hall 200 nurse medication cart) reviewed for drug storage. The facility failed to ensure the nurse medication cart on Hall 200 was locked and supervised. This failure could place residents at risk for possible misappropriation of property or drug diversion.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the physician was consulted for a change of condition for 1 of 10 residents reviewed for notification of changes. (Resident #1) Resident #1 returned to the facility from the hospital on [DATE]. Hospital discharge records included a recommendation to follow-up with cardiologist due to suspected left ventricular apex aneurysm (a bulge or weakened area in the wall of the heart's ventricles-lower pumping chambers). The facility did not consult or notify the physician of the recommendation. This failure could place residents at risk for delay in treatment and decreased quality of life.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure the medical record of each resident was accurately documented in accordance with accepted professional standards and practices for 1 of 10 residents (Resident #1) reviewed for medical records. The facility failed to ensure a recommendation for a cardiologist referral dated 11/27/23 was documented in Resident #1's clinical record. This failure could place residents at risk for delayed care and appropriate interventions.

Inspectors wroteBased on interview and record review, the facility failed to ensure the coordination of assessments with the Pre-admission Screening and Resident Review program (PASRR) was provided for 1 of 19 residents reviewed for PASRR screenings. (Resident #36). The facility failed to ensure Resident #36's PASRR Level 1 indicated a diagnosis of mental illness, although the diagnosis was present upon admission. This failure could place residents at risk for not receiving needed assessments, care, and specialized services to meet their needs.

Inspectors wroteBased on observation, interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that includes included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 2 of 19 residents (Residents #63 and #78) reviewed for comprehensive care plans. 1. The facility failed to ensure Resident #63 was care planned for tracheostomy care. 2. The facility failed to follow physician orders related to enteral feeding (a form of nutrition that is delivered into the digestive system as liquid) through a gastrostomy tube(g-tube) (a surgically placed device used to give direct access to the stomach for supplementally feeding, hydration and medication) for Resident #78. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide necessary respiratory care consistent with professional standards of practice, the resident's care plan, goals, and preferences for 1 of 19 residents reviewed for respiratory care and services. (Resident #20) The facility did not provide Resident #20's oxygen concentrator with clean filters. The two filters were covered with thick layers of tan powdery substance. This failure could place residents who required respiratory care at risk of not receiving proper care and treatment and decreased quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide or obtain routine dental services from an outside resource to meet the needs of each resident for 1 of 19 residents (Resident #55) reviewed for dental services. The facility did not request dental services for Resident #55, who did not have upper dentures since admission on [DATE]. This failure could place the residents at risk of not receiving the appropriate care and services to maintain their well-being.