Signature Healthcare at Jefferson Manor Rehab & We

Inspectors wroteFacility failed to follow policy prior to self-administering neb treatments.

Inspectors wroteBased on observation, interview, and review of facility policy, it was determined the facility failed to ensure drugs and biologicals were stored appropriately, without being expired, for one (1) of two (2) medication storage rooms, and two (2) of five (5) medication carts. A tour of the blue medication room, on 06/04/2024 at 11:45 AM, revealed a tube of Iodosorb with an expiration date of 02/2022, a tube of Medihoney with expiration date of 12/11/2022, and a tube of HydrofaraBlue with expiration date of 02/01/2021. Additionally, observation on 06/04/2024 at 12:50 PM, of the [NAME] Unit, Medication Cart #1, revealed the following expired medications: a bottle of nitroglycerine 0.4 milligram (mg) with an expiration date of 11/16/2023; Atrovent 17 micrograms (mcg ) hydrofluoroalkane (HFA) inhaler with an opened date of 04/24/2024; and a Miralax bottle opened on 01/29/2023. [...]

Inspectors wroteBased on observation, interview, record review, and review of facility policy, it was determined the facility failed to ensure two (2) of 49 sampled residents (Resident (R)16 and R47) were assessed for self-administration of medications to ensure the practice was clinically appropriate. Observation on 06/03/2024 at 2:27 PM, revealed a bottle of Flonase Allergy Relief nasal spray on R16's overbed table. However, there was no documented evidence of Physician's Orders for self administration of medications. Additionally, observation, on 06/04/2024 at 12:37 PM, revealed a small yellow pill on R47's lunch tray. However, there was no documented evidence of Physician's Orders for self administration of medications.

Inspectors wroteBased on interview, record review, review of the Centers for Medicare and Medicaid Services (CMS), Form Instructions for the Notice of Medicare Non-Coverage (NOMNC) CMS-10123, review of the CMS site, Form Instructions Advance Beneficiary Notice of Non-coverage (ABN) OMB Approval Number: 0938-0566 and review of facility policy, it was determined the facility failed to issue the appropriate notice for termination of Medicare part A benefits for two (2) of three (3) residents reviewed for beneficiary notification out of a total sample of 49 residents (Resident (R) 67 and R73). These failures had the potential to result in a lack of understanding of appeal rights and/or the termination of the current level of care against the resident's/representative's wishes.

Inspectors wroteBased on interview, record review and review of the Kentucky Board of Nursing AOS #09 - Wound Assessment, Staging, and Treatment published in December 2023, it was determined the facility failed to ensure services provided or arranged by the facility meet professional standards of quality for two (2) of 49 sampled residents (Resident (R)71 and R1). The facility failed to have qualified wound care staff and physician oversight related to wound care.

Inspectors wroteBased on observation, interview, record review, and review of facility policy, it was determined the facility failed to ensure that adequate assistive devices were implemented to prevent accidents for one (1) of four (4) sampled residents reviewed for falls out of a total sample of 49 residents, Resident (R)76). R76 was found on the floor on 04/20/2024, and the Interdisciplinary Team (IDT) conducted a root cause analysis and determined the resident attempted to get out of his bed and fell. A new fall intervention dated 05/04/2024, revealed the resident's bed was to be in a low position, when he was in bed. However, observations on 06/04/2024 revealed staff failed to ensure the bed was in the lowest position while the resident was in bed.

Inspectors wroteBased on observation, interview, and record review, it was determined 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 two (2) of two (2) sampled residents observed for wound care out of a total sample of 49 residents, Resident (R)1 and R71. During observation of wound care for R71, on 06/04/2024, Wound Care Nurse (WCN)1 failed to implement infection control procedures as evidenced by failure to clean/disinfect the table top prior to placing a barrier in which to place wound supplies; failure to clean/disinfect scissors before using them to cut the Kerlix which she packed in the resident's wound; [...]

Inspectors wroteBased on observation, interview, and facility policy review, it was determined the facility failed to store and serve food in accordance with professional standards for food service safety. Observation revealed expired milk in the refrigerator and record review revealed food temperatures and sanitation temperatures not documented.

Inspectors wroteBased on observation, interview, record review, and facility policy review, it was determined the facility failed to follow the care plan for one (1) of four (4) sampled residents, Resident #70. The facility assessed the resident was at risk for falls with an intervention to have the call light within reach. However, observation revealed the resident's call light was not functional.

Inspectors wroteBased on observation, interview, record review, and facility policy review, it was determined the facility failed to ensure one (1) of four (4) sampled residents, Resident #70, had a functioning call light to ensure safety. Observation revealed the call light box/jack was pulled away from the wall and not functional.

Inspectors wroteBased on observation, interview, facility policy review, and controlled mediation count review, it was determined the facility failed to account for controlled medication for one (1) of eighteen (18) sampled residents, Resident #26. Observation and record review revealed an inaccurate account of the resident's medication.

Inspectors wroteBased on observation, interview, and facility policy review, it was determined the facility failed to ensure proper storage of medications in two (2) of six (6) medication carts, [NAME] Hall Medication Carts 1 and 2. Observation revealed sixty-one (61) loose, unpackaged pills in the carts. In addition, Medication Cart #1 was left unlocked and unattended and medications were left unattended at Resident #37's bedside.

Inspectors wroteBased on observation, interview, record review, and facility policy review, it was determined the facility failed to maintain an effective infection control program to help prevent the development and transmission of disease and infection for one (1) of six (6) sampled residents, Resident #13. Observation of Resident #13's Oxygen tubing revealed it was dated 07/11/18, several months prior to the survey.

Inspectors wroteBased on interview, record review, and facility policy review, it was determined the facility failed to provide pneumococcal vaccinations to three (3) of eighteen (18) sampled residents, Resident #9, #22, and #70.