Inspection Reports for Jefferson Healthcare

The complaint investigation was substantiated. A resident was ejected from a wheelchair during transport on 9/8/25 due to failure to secure the resident with a lap belt. The resident sustained facial injuries and was hospitalized. The driver failed to notify 911 or facility staff at the time of the incident. The facility was notified on 9/18/25 and corrective actions were implemented immediately.

The facility failed to ensure the resident's environment was free from accident hazards during transport, as the resident was not secured with a lap belt and was ejected from the wheelchair, causing injury. The driver did not notify 911 or facility staff immediately. The facility took corrective actions including staff education, implementation of transport checklists, and supervisor ride-alongs.

The investigation was complaint-driven, focusing on fall prevention failures for Resident #16. The resident had multiple unwitnessed falls, including one with head injury. The complaint was substantiated by findings of inadequate fall prevention measures and lack of proper documentation.

The facility failed to implement appropriate fall prevention interventions for Resident #16, who had multiple unwitnessed falls and was at risk due to decreased safety awareness and physical weakness. Despite physician orders and care plans, fall prevention measures such as bed cane rails, fall mats, and bed positioning were not consistently implemented. Neuro checks were not documented after a fall where the resident hit their head, and staff were unaware or unable to provide evidence of proper fall prevention protocols.

The facility was found deficient in multiple areas including failure to maintain resident dignity and timely assistance, improper management of resident funds, incomplete resident assessments, inadequate care planning, insufficient assistance with activities of daily living, failure to apply prescribed braces, inadequate fall prevention measures, improper medication administration, insufficient staffing levels especially on weekends, lack of staff competencies, failure to maintain infection control practices including TB testing and equipment sanitation, and failure to provide required vaccinations.

The complaint was substantiated based on interviews and statements from the resident, staff witnesses, and investigation. The resident felt safe but acknowledged the incident was inappropriate. CMT A received corrective action and was later terminated for poor performance and disrespectful behavior.

The facility failed to protect one sampled resident from verbal abuse when CMT A was witnessed yelling and using inappropriate language towards the resident during medication administration. Multiple staff statements and interviews confirmed the incident, and corrective actions were taken including termination of CMT A.

The facility failed to properly screen new employees for tuberculosis prior to hire, did not ensure proper infection control practices during wound care for sampled residents, failed to maintain sanitary medication carts, and did not enforce appropriate PPE use and mask-wearing among staff, residents, and visitors during a COVID-19 outbreak. Doors to COVID-19 positive residents' rooms were often left open, and equipment was not properly designated or cleaned.

The facility was found deficient in multiple areas including failure to deposit resident funds in interest bearing accounts, inaccurate documentation of resident code status, incomplete criminal background checks for new hires, untimely and unsigned Minimum Data Set (MDS) assessments, incomplete baseline care plans, inadequate wound care documentation and infection control practices, delayed response to call lights, insufficient bathing and colostomy care, medication administration errors, unsecured medication storage, improper food safety and sanitation practices, lack of restorative therapy services, and failure to properly screen employees for tuberculosis.

The complaint investigation found substantiated resident-to-resident abuse on 6/5/23. Resident #1 was witnessed by CMT A touching Resident #2's left breast. Resident #2 reported the incident and was upset. The Administrator and law enforcement were involved, and the incident was confirmed as abuse.

The facility failed to ensure Resident #2 was free from resident-to-resident abuse when Resident #1 inappropriately touched Resident #2's left breast. The incident was witnessed by a Certified Medication Technician (CMT A), reported to nursing staff and administration, and was determined to be abuse by the Administrator. The facility took immediate corrective actions including staff education and updating resident care plans.

The facility had multiple deficiencies including failure to honor residents' advance directives, failure to provide required Medicare notices, incomplete background checks for employees, incomplete and untimely resident assessments, inadequate care plans for residents' needs and medications, insufficient activity programs, incomplete hospice documentation, inadequate pressure ulcer care, medication administration errors, unlocked medication carts, improper medication refrigerator temperature monitoring, insufficient staff training and competency validation, incomplete employee tuberculosis screening, and inadequate infection prevention and control program implementation.