Inspection Reports for
Jefferson Healthcare

MO00232324, MO00232505; substantiation not stated in the document.

Two deficiencies were cited: one federal health deficiency for failure to protect a resident from abuse and neglect, and one Missouri state licensure deficiency for failure to develop and implement abuse/neglect policies. The federal finding documents a staff member yelling and using profane language toward a sampled resident and crushing the resident's medications; the state citation refers to that federal finding.

20 deficiencies were cited: 11 federal Life Safety/Emergency Preparedness deficiencies addressing emergency preparedness policies, roles/waivers, communications, testing/exercises, egress/door locking, sprinkler maintenance, out-of-service procedures, portable fire extinguishers, fire drills, door maintenance/labels, and electrical power strips; and 9 Missouri state licensure deficiencies citing 19 CSR rules that reference the related K/E findings.

MO00210242; substantiation/outcome not stated.

Two deficiencies: one federal deficiency for pharmacy/controlled substance management involving a narcotic count discrepancy for a resident, and one Missouri state licensure deficiency for inadequate policies/procedures referencing the federal finding.

The file contains 11 federal Life Safety/Emergency Preparedness deficiencies addressing emergency preparedness planning and training, subsistence/water supply, and multiple fire/life-safety system problems (ceiling/sprinkler issues, hazardous area doors, fire alarm installation and notification, sprinkler impairments, door maintenance, electrical system maintenance, and oxygen storage). It also contains 9 Missouri State Form deficiencies that reference and cite the same fire safety and emergency preparedness concerns.

Four deficiencies were cited: two federal deficiencies addressing pharmacy services, medication delivery/reconciliation and medication administration errors, and two Missouri state licensure citations referencing those federal findings.

There are 7 federal Life Safety (K-tag) deficiencies involving means of egress, exit signage, emergency lighting, fire alarm installation, testing and maintenance, HVAC ventilation, and electrical power/extension cord use; and 13 Missouri state licensure deficiencies citing the same topics and referring to the federal K findings.

Five deficiencies were cited: three federal health deficiencies for accuracy of assessments/MDS coding, psychotropic PRN medication use, and routine/emergency dental services; and two Missouri state licensure deficiencies citing nursing care per resident condition and the facility social services program that refer to the federal findings.

There are 13 federal health survey deficiencies addressing resident notices/beneficiary notices, transfer/bed-hold policies, care planning/timing, medication storage and administration, dialysis coordination, infection prevention, food sanitation and waste disposal, and safe transfer practices. There are 10 Missouri state licensure deficiencies that primarily cross-reference and cite the federal findings.

There are 10 federal deficiencies (life safety and emergency preparedness) concerning emergency preparedness, fire alarm installation, sprinkler installation and testing/maintenance, portable fire extinguishers, fire drills, smoking regulations, electrical equipment/extension cord use, plumbing/backflow inspection, and facility maintenance training. There are 9 Missouri state licensure deficiencies addressing fire extinguishers, complete fire alarm and sprinkler system requirements, ashtrays/smoking disposal, fire drill records, extension cord use, policies/procedures, employee orientation/continuing education, and plumbing.

Nine deficiencies were cited: five federal life-safety (K-tag) deficiencies related to fire drills, door inspection/testing, electrical receptacles and wiring, emergency electrical system testing, and electrical equipment testing; and four Missouri state deficiencies addressing fire hazard, fire drill requirements/evacuation, electrical wiring/equipment maintenance, and extension cord/duplex receptacle requirements. The Emergency Preparedness portion did not result in deficiencies.

There are 11 federal deficiencies addressing staff background checks/hiring, transfer/bed-hold/notification practices, comprehensive care planning (including oxygen), professional standards for equipment/alarms, hearing/vision services, pharmacy/narcotic counts and medication management (including psychotropics), medication storage/labeling/security, dental services, and infection control/TB screening. There are 9 Missouri State Form deficiencies addressing criminal background checks, communicable disease/TB screening, medication storage and controlled substance records, nursing care per resident condition, infection control, social services, emergency discharge/transfer notices, and personal belongings disposition.

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.

MO00232324, MO00232505; substantiation not stated in the document.

Two deficiencies were cited: one federal health deficiency for failure to protect a resident from abuse and neglect, and one Missouri state licensure deficiency for failure to develop and implement abuse/neglect policies. The federal finding documents a staff member yelling and using profane language toward a sampled resident and crushing the resident's medications; the state citation refers to that federal finding.

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.

20 deficiencies were cited: 11 federal Life Safety/Emergency Preparedness deficiencies addressing emergency preparedness policies, roles/waivers, communications, testing/exercises, egress/door locking, sprinkler maintenance, out-of-service procedures, portable fire extinguishers, fire drills, door maintenance/labels, and electrical power strips; and 9 Missouri state licensure deficiencies citing 19 CSR rules that reference the related K/E findings.

One federal health deficiency was cited for resident abuse/neglect (F600). Past noncompliance was noted and the facility investigated and provided staff education.

MO00210242; substantiation/outcome not stated.

Two deficiencies: one federal deficiency for pharmacy/controlled substance management involving a narcotic count discrepancy for a resident, and one Missouri state licensure deficiency for inadequate policies/procedures referencing the federal finding.

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.

The file contains 11 federal Life Safety/Emergency Preparedness deficiencies addressing emergency preparedness planning and training, subsistence/water supply, and multiple fire/life-safety system problems (ceiling/sprinkler issues, hazardous area doors, fire alarm installation and notification, sprinkler impairments, door maintenance, electrical system maintenance, and oxygen storage). It also contains 9 Missouri State Form deficiencies that reference and cite the same fire safety and emergency preparedness concerns.

Four deficiencies were cited: two federal deficiencies addressing pharmacy services, medication delivery/reconciliation and medication administration errors, and two Missouri state licensure citations referencing those federal findings.

MO00196180; substantiation not stated in the record.

One federal health deficiency was cited for resident rights/exercise of rights concerning dignity, staff rudeness, failure to respond to call lights, and problems receiving medications; past noncompliance was noted.

No health or emergency preparedness deficiencies were cited. The surveyor found the facility in compliance with 42 CFR 483.73 related to E-0024(b)(6) and with CMS and CDC recommended practices to prepare for COVID-19.

No health survey deficiencies were cited; the survey focused on COVID-19 infection control and emergency preparedness and the facility was found in compliance with CMS and CDC recommended practices and 42 CFR 483.73 related to emergency preparedness.

MO00188712; the survey documents an investigation and actions taken but does not state whether the complaint was formally adjudicated as substantiated.

One federal health deficiency for resident rights/dignity and staff conduct (spitting incident) was cited. Past noncompliance was noted in the file.

No federal health or emergency preparedness deficiencies were cited. Initial comments indicate the facility was found in compliance with 42 CFR 483.73 (emergency preparedness) and CMS/CDC recommended infection control practices for COVID-19.

No deficiencies were cited; the survey found the facility in compliance with COVID-19 emergency preparedness and infection control requirements.

Zero deficiencies were cited. The survey addressed emergency preparedness and infection control and found the facility in compliance with applicable CMS/CDC guidance.

There are 7 federal Life Safety (K-tag) deficiencies involving means of egress, exit signage, emergency lighting, fire alarm installation, testing and maintenance, HVAC ventilation, and electrical power/extension cord use; and 13 Missouri state licensure deficiencies citing the same topics and referring to the federal K findings.

Five deficiencies were cited: three federal health deficiencies for accuracy of assessments/MDS coding, psychotropic PRN medication use, and routine/emergency dental services; and two Missouri state licensure deficiencies citing nursing care per resident condition and the facility social services program that refer to the federal findings.

There are 13 federal health survey deficiencies addressing resident notices/beneficiary notices, transfer/bed-hold policies, care planning/timing, medication storage and administration, dialysis coordination, infection prevention, food sanitation and waste disposal, and safe transfer practices. There are 10 Missouri state licensure deficiencies that primarily cross-reference and cite the federal findings.

There are 10 federal deficiencies (life safety and emergency preparedness) concerning emergency preparedness, fire alarm installation, sprinkler installation and testing/maintenance, portable fire extinguishers, fire drills, smoking regulations, electrical equipment/extension cord use, plumbing/backflow inspection, and facility maintenance training. There are 9 Missouri state licensure deficiencies addressing fire extinguishers, complete fire alarm and sprinkler system requirements, ashtrays/smoking disposal, fire drill records, extension cord use, policies/procedures, employee orientation/continuing education, and plumbing.

Nine deficiencies were cited: five federal life-safety (K-tag) deficiencies related to fire drills, door inspection/testing, electrical receptacles and wiring, emergency electrical system testing, and electrical equipment testing; and four Missouri state deficiencies addressing fire hazard, fire drill requirements/evacuation, electrical wiring/equipment maintenance, and extension cord/duplex receptacle requirements. The Emergency Preparedness portion did not result in deficiencies.

There are 11 federal deficiencies addressing staff background checks/hiring, transfer/bed-hold/notification practices, comprehensive care planning (including oxygen), professional standards for equipment/alarms, hearing/vision services, pharmacy/narcotic counts and medication management (including psychotropics), medication storage/labeling/security, dental services, and infection control/TB screening. There are 9 Missouri State Form deficiencies addressing criminal background checks, communicable disease/TB screening, medication storage and controlled substance records, nursing care per resident condition, infection control, social services, emergency discharge/transfer notices, and personal belongings disposition.