Jones Co Rest Home

Inspectors wroteBased on interviews, observation, record review, facility investigation review, and facility policy review, the facility failed to provide adequate supervision to prevent Resident #1 and Resident #2 from eloping from the facility on 5/18/26 at 5:41 PM. The facility staff did not know that Resident #1 and Resident #2 were out of the facility on the facility grounds for 11 minutes. This concern was identified for two (2) of eight (8) residents reviewed for diagnoses of Alzheimer's disease and dementia (Resident #1 and Resident #2). The facility's failure to provide adequate supervision resulted in Resident #1 and Resident #2 leaving the facility unsupervised, placing these residents and other residents with diagnoses of Alzheimer's disease and dementia at risk for elopement and the likelihood of serious injury, harm, impairment, or death. [...]

Inspectors wroteBased on interview, record review, and facility policy review the facility failed to develop and implement a comprehensive, person-centered care plan and individualized interventions, as evidenced by not addressing ongoing behavioral symptoms and providing individualized comfort care interventions, despite a known history of psychotic and aggressive behaviors, which resulted in Resident #10 having frequent behavioral episodes, refusal of medications and food, and frequent combative interactions with staff.for one (1) of twenty-three (23) residents reviewed for care planning.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the ongoing provision of behavioral health services for a cognitively impaired resident with severe, escalating behaviors following discharge from a behavioral health unit and despite continued aggression, delusions, and medication refusal, the facility discontinued behavioral health services without a documented rationale, contributing to ongoing physical aggression toward staff and others for one (1) of 23 sampled residents.

Inspectors wroteBased on observation, interviews, record reviews, and facility policy review, the facility failed to honor resident food dislikes by placing food items on meal trays that were identified as dislikes for one (1) of four (4) days of observation. Resident #58.

Inspectors wroteBased on interview and record review the facility failed to provide a reason for a resident transfer for one (1) of 23 residents sampled. Resident #5 Findings Include: A review of the facility's Notice of Transfer or Discharge dated 09/02/24 revealed there was no explanation for the resident's discharge to the hospital. A review of the facility's Notice of Transfer or Discharge dated 12/14/24 revealed there was no explanation for the resident's discharge to the hospital. A record review of the facility's admission Record revealed the facility admitted the resident on 5/20/16 with diagnoses including Heart Failure. On 3/20/25 at 8:05 AM, an interview with the Social Services Director revealed the Charge Nurse is responsible for filling in the Notice of Resident Transfer or Discharge form and the Business Office Coordinator mails the form to the Resident Representative (RR). [...]

Inspectors wroteBased on interviews, record review, and facility policy review, the facility failed to complete a Significant Change in Status Minimum Data Set (MDS) assessment after a resident experienced two (2) or more declines in activities of daily living and an increase in behavioral symptoms for one (1) of twenty-three (23) sampled residents. Resident #10.

Inspectors wroteBased on interviews, record review, and facility policy review, the facility failed to notify the state mental health authority following a significant change in status for one (1) of two (2) residents reviewed for Preadmission Screening and Resident Review (PASRR) Level II.

Inspectors wroteBased on observation, staff interviews and facility policy review, the facility failed to store food in accordance with professional standards for food service safety related to food items not dated with a use-by date, food items not discarded by the use-by date, spoiled foods not discarded, food items without an identifying label, food items improperly stored, and food items opened and not sealed for one (1) of three (3) kitchen observations and had the potential to affect all residents who receive food items from the kitchen. Findings Include: A review of the facility's policy, Food and Supply Storage, revised 1/22, revealed, . [...]

Inspectors wroteBased on interviews, record review, and facility policy review the facility failed to ensure grievances related to dietary services were resolved for ten (10) of 24 sampled residents. (Resident #1, #18, #22, #42, #58, #61, #67, #94, #96 and #104)

Inspectors wroteBased on observation, staff interviews, record review, and facility policy review, the facility failed to ensure staff washed or sanitized hands during Percutaneous Endoscopic Gastrostomy (PEG) site care for one (1) of two (2) residents reviewed with PEG tubes. Resident # 38 Findings Include: Review of the facility's policy, Infection Prevention and Control Program Policy, revised 8/22/2019, revealed, Purpose: 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 . During PEG site care, on 10/24/23 at 10:20 AM, for Resident # 38, Licensed Practical Nurse (LPN) #1 did not wash or sanitize her hands or change her gloves after removing the soiled dressing from the PEG site. She used the same gloves to clean the site. [...]

Inspectors wroteBased on interviews, record review, and facility policy review, the facility failed to provide written notification of transfer to the resident and the Resident's Representative (RR), for a resident transferred to the hospital for one (1) of two (2) resident records reviewed for hospitalizations.

Inspectors wroteBased on interviews, record review and facility policy review, the facility failed to provide the Resident and the Resident Representative (RR) with written notification of the bed hold policy at the time of transfer to the hospital for one (1) of two (2) residents reviewed for hospitalizations.

Inspectors wroteBased on staff interview, record review, and facility policy review, the facility failed to transmit a discharge Minimum Data Set (MDS) Assessment for one (1) of 24 residents reviewed for MDS assessments. (Resident #78) Findings Include: Review of facility's, MDS (Minimum Data Set), CAA (Care Area Assessment), and Care Plan Documentation Policy, revised 10/18/2019, revealed, .It is the policy of this facility to provide documentation in the medical record for MDS, CAA, and care plan purposes . Record review of the Transfer/Discharge Report revealed the facility admitted Resident #78 on 6/5/23 with a diagnosis of Alzheimer's Disease. Record review of the Progress Notes revealed a Discharge Summary note, dated 7/2/23 at 12:30 (PM), for Resident #78 for .1230 (12:30 PM) Coroner called to pronounce death . [...]

Inspectors wroteBased on observation, staff interviews, and facility policy reviews, the facility failed to properly sanitize the food processors for pureed diets which could affect 11 of 11 residents receiving puree diets for one (1)of three (3) days survey.

Inspectors wroteBased on observation, staff interviews, record reviews, and facility policy review, the facility failed to maintain a medication error rate of less than five percent (5%) for one of six (6) medication administration observations. The medication error rate was seven (7) percent. Resident #66.

Inspectors wroteBased on observation, staff interviews, record reviews, and facility policy reviews the facility failed to prevent the possible spread of infection as evidenced by the wound care nurse touching multiple surfaces with contaminated gloves for one (1) of four (4) wound care observations. Resident #74. Findings Include: The facility's policy, Clean Dressing Change, reviewed date 3/11/2020 revealed, To provide wound care in a manner to decrease potential for infection and/or cross-contamination. On 03/04/21, at 08:54 AM, an observation of wound care being done by Licensed Practical Nurse (LPN) #1/Wound Care Nurse. LPN #1/Wound Care Nurse applied clean gloves and closed the privacy curtain with right gloved hands. She picked up the bed control, adjusted the bed, and removed Resident #74's wound dressing without changing gloves. [...]