Inspection Reports for
Jefferson City Manor

The complaint investigation found that staff failed to replace the resident's wanderguard as ordered, leading to the resident leaving the facility without staff knowledge. The resident was found by a community member and returned with an abrasion. Staff documented multiple days without wanderguard placement and no replacement attempts were documented. Interviews with staff and administration confirmed lack of notification and replacement efforts prior to the incident.

Facility staff failed to replace the resident's wanderguard after identifying it was missing, resulting in the resident leaving the facility unnoticed. The facility took corrective actions including increasing wanderguard checks, staff in-service, and updating the resident's care plan.

Complaint #2649088 regarding failure to document and administer wound treatments as ordered by the physician for two residents. The complaint was substantiated based on observations, interviews, and record reviews.

Facility staff failed to document wound treatments as directed by the physician for two residents out of three sampled. Documentation on the Treatment Administration Record (TAR) was missing for multiple dates, and interviews revealed inconsistent treatment administration and documentation practices.

The complaint investigation was substantiated as the facility failed to properly investigate and report suspected abuse, complete required assessments, develop care plans, maintain sufficient staffing, and ensure food safety and staff training.

The facility failed to thoroughly investigate and document bruises of unknown origin on a resident and did not complete required assessments and care plans for residents with significant changes in condition. Additionally, the facility failed to maintain sufficient nursing staff and ensure timely responses to call lights, among other deficiencies.

The facility failed to follow treatment orders for multiple residents, including failure to administer prescribed creams, notify physicians or pharmacies about unavailable medications, ensure oxygen was in place and at the correct flow rate, document daily weights, and perform ordered urinalysis tests. Several policy and procedural deficiencies were also noted.

The facility failed to maintain an Emergency Preparedness Plan that included tracking of on-duty staff during emergencies and failed to provide required emergency preparedness training to all staff. Life safety code violations included obstructed exit corridors and inadequate fire drill documentation. The facility also failed to provide adequate training on medical gases and cylinders safety.

The facility was found deficient in multiple areas including failure to thoroughly investigate and document bruises of unknown origin, incomplete significant change assessments, inadequate comprehensive care plans, failure to hold care plan meetings with residents and representatives, failure to meet professional nursing standards including medication administration and oxygen use, failure to maintain proper food temperatures, insufficient nursing staff to timely respond to call lights, and inadequate nurse aide training and education.

The facility failed to obtain a timely advance directive for a resident who received CPR despite a Do Not Resuscitate (DNR) order. Staff did not consistently document or follow residents' code status, leading to inappropriate resuscitation efforts.

The complaint investigation found that staff initiated CPR on a resident with a DNR order due to failure to verify code status promptly. The Director of Nursing, administrator, and Licensed Practical Nurse interviewed were unaware or uncertain why staff did not follow the resident's wishes. The LPN stated he/she erred on the side of caution and was unaware of the code status documentation procedures.

The facility staff failed to obtain a timely advanced directive for a resident who elected DNR and inconsistently documented the resident's code status, resulting in staff initiating CPR before discovering the resident's DNR status. Interviews revealed staff were unaware or did not follow proper procedures for identifying code status.

The facility staff failed to provide adequate hygiene care, including nail care and facial hair assistance, for four out of five sampled residents. Observations and record reviews showed long nails with debris and unkempt facial hair, and shower sheets lacked documentation of provided care. Interviews with staff and residents confirmed these deficiencies, highlighting potential infection control and dignity concerns.

The facility failed to provide adequate personal hygiene care, including nail care and assistance with facial hair, to four sampled residents. Observations and record reviews showed residents had long nails with debris and unkempt facial hair, despite care plans directing staff to provide such care.

The facility failed to develop and implement a comprehensive person-centered care plan for one resident and failed to update care plans at least quarterly for two other residents, despite policies requiring timely updates. Interviews with the MDS Coordinator, administrator, and Director of Nursing confirmed responsibility for care plan updates and ongoing efforts to resolve these issues.

The facility failed to develop and update comprehensive person-centered care plans for sampled residents in a timely manner, as required by federal regulations. The MDS Coordinator and Director of Nursing acknowledged responsibility and efforts to correct the deficiencies.

The complaint investigation involved allegations of failure to protect resident privacy, failure to report suspected abuse or theft (missing money and wallet), failure to provide ordered wound care, and unsafe medication storage and administration practices. The facility census was 71. The investigation included interviews with residents, staff including Licensed Practical Nurses, Certified Medication Technician, Director of Nursing, Social Services Designee, Maintenance Director, Therapy Director, Housekeeper, and the Administrator. The investigation found multiple deficiencies as described.

The facility failed to protect residents' privacy by leaving medical information visible in public areas, failed to report allegations of misappropriation of money in a timely manner, failed to document wound treatment administration as ordered, and failed to ensure medications were securely stored and monitored.

The complaint investigation substantiated violations related to privacy breaches and failure to report misappropriation of resident money. The facility census was 71 at the time of the investigation.

The facility failed to protect residents' privacy as medical information was left face up on nurse station desks visible to others. Additionally, the facility failed to report allegations of misappropriation of money for two residents in a timely manner and failed to meet professional standards in care planning and medication storage.

The facility was found deficient in multiple areas including nursing coverage, medication storage and labeling, food safety and sanitation, and hospice services coordination. Deficiencies were documented with specific regulatory citations and corrective plans.

The facility failed to provide RN coverage for eight consecutive hours daily, maintain proper medication labeling and storage, ensure food safety and kitchen sanitation, and document coordinated hospice care plans for residents receiving hospice services.

The facility was found deficient in emergency preparedness training documentation, sprinkler system maintenance, fire barrier wall maintenance, fire drill execution, smoking signage, and electrical equipment safety. Several corrective actions were planned to address these deficiencies.

The facility failed to ensure residents were free of significant medication errors, specifically a failure to administer prescribed medications Metolazone and Torsemide to a resident, resulting in hospitalization. The facility lacked a policy for handling unavailable medications and had documentation and communication deficiencies related to medication administration.

The complaint investigation found that the resident did not receive the ordered medications Metolazone and Torsemide on 11/3/23 and 11/4/23, leading to respiratory failure and hospitalization. Staff interviews revealed confusion and lack of clarity about responsibilities for medication order entry, delivery reconciliation, and notification procedures. The resident's family raised concerns about the missing medications. The physician confirmed the importance of timely medication administration and expected notification if medications were unavailable.

The facility failed to ensure the resident was free from significant medication errors by not administering Metolazone and Torsemide as ordered and failing to notify the physician about the medication unavailability. This led to the resident's hospitalization with acute chronic hypoxic respiratory failure, pulmonary edema, and chronic kidney disease Stage IV. The facility lacked a policy for handling situations when medications could not be started as ordered.

The facility failed to maintain sprinkler systems free of obstructions and debris, did not conduct required fire drills properly, and failed to maintain nonrated corridor doors to ensure they latched properly. Night-lights were missing in multiple resident rooms and common areas.

The facility was found deficient in multiple areas including failure to maintain resident dignity, incomplete baseline care plans, inadequate assistance with activities of daily living, improper pressure ulcer care, lack of range of motion interventions, insufficient fall prevention measures, improper catheter care, incomplete respiratory care orders and plans, inappropriate use and monitoring of antipsychotic medications, food safety violations including ice machine drainage and ceiling cleanliness, infection control breaches including hand hygiene and wound care, and failure to conduct regular bed rail entrapment assessments.

The facility failed to meet professional standards of quality in documenting treatments and services in the Treatment Administration Record (TAR) for five residents. Staff did not document treatments such as nebulizer and oxygen tubing changes, wound care, and CPAP use as ordered by physicians.

The facility failed to prevent the misappropriation of one resident's pain medication by an agency staff member without authorization. The investigation involved staff interviews, police involvement, and corrective actions to prevent further incidents.

The facility failed to provide safe Hoyer lift transfers for residents, resulting in accident hazards. Staff did not follow proper procedures to keep the Hoyer lift base widened during transfers, risking resident safety.

The facility failed to conduct required monthly and annual functional tests of emergency lighting, maintain corridor doors to resist smoke passage, and conduct fire drills under varying conditions as required by NFPA 101 Life Safety Code.

The facility failed to notify the resident's physician and responsible party of a change in condition related to a pressure ulcer. The facility also failed to maintain the integrity of a healed pressure ulcer and follow physician orders, resulting in the reopening of the pressure ulcer.

The facility was found deficient in food safety practices including improper thawing and storage of food, failure to maintain infection prevention protocols such as hand hygiene and proper handling of medical supplies, and failure to ensure staff properly used the resident call system. Multiple residents were affected by these deficiencies.

The facility failed to conduct a full-scale emergency preparedness exercise and did not maintain required smoke barrier walls with proper fire resistance ratings. Additionally, power strips were improperly used in resident rooms, increasing fire hazard risk.

The facility failed to meet professional standards of care by not obtaining physician-ordered treatments and not documenting wound care treatments for multiple residents. The follow-up inspection found continued deficiencies in wound care documentation and treatment, indicating the deficiency was uncorrected.

The complaint investigation was substantiated. It involved an incident where Resident #1 attacked Resident #2 in Resident #2's room. The investigation found Resident #1 was confused and agitated, and the facility failed to provide adequate protective oversight.

The facility failed to provide protective oversight to prevent physical abuse between residents and failed to meet professional standards in obtaining a urine analysis as ordered by a physician. Additionally, the facility did not respond timely to call lights and did not provide adequate bathing and personal hygiene care to several residents.