Deficiencies (last 8 years)
Deficiencies (over 8 years)
15.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
187% worse than Missouri average
Missouri average: 5.5 deficiencies/year
Deficiencies per year
40
30
20
10
0
Occupancy
Latest occupancy rate
53% occupied
Based on a September 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Complaint Investigation
Census: 64
Deficiencies: 1
Date: Sep 18, 2025
Visit Reason
The inspection was conducted due to a complaint investigation following an incident where a resident was not properly secured with a lap belt in the facility van during transport, resulting in the resident being ejected from the wheelchair and sustaining facial injuries.
Complaint Details
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.
Findings
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.
Deficiencies (1)
Failure to ensure a nursing home area is free from accident hazards and provide adequate supervision to prevent accidents, specifically failure to secure a resident with a lap belt during transport resulting in injury.
Report Facts
Facility census: 64
Incident date: Sep 8, 2025
Date of driver training: Aug 4, 2025
Date of report notification: Sep 18, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Transportation Driver A | Transportation Driver | Named in the finding for failing to secure resident during transport and not notifying facility or 911 |
| Dialysis Nurse A | Dialysis Nurse | Reported resident injury to facility and communicated with facility staff |
| Director of Nursing | Director of Nursing (DON) | Received injury report, investigated incident, and communicated with staff and administration |
| Administrator | Facility Administrator | Notified of incident and involved in investigation and corrective actions |
Inspection Report
Complaint Investigation
Census: 64
Deficiencies: 3
Date: Apr 4, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to implement adequate fall prevention measures for a sampled resident.
Complaint Details
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.
Findings
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.
Deficiencies (3)
Failure to implement fall prevention measures to reduce hazards and risks for Resident #16.
Lack of documentation of neurological assessments after a fall where the resident hit their head.
Failure to implement physician-ordered fall prevention interventions such as bed cane rails and fall mats.
Report Facts
Resident census: 64
Sampled residents: 16
Falls documented for Resident #16: 7
Duration of antibiotic treatment: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Medication Technician D | Certified Medication Technician (CMT) | Interviewed regarding awareness of resident's call light and fall history |
| Licensed Practical Nurse A | Licensed Practical Nurse (LPN)/Infection Preventionist (IP) | Interviewed regarding staffing and fall prevention measures |
| Maintenance Director | Maintenance Director | Interviewed regarding installation of call light and bed cane rails |
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding fall protocols and documentation |
| Director of Rehabilitation | Director of Rehabilitation | Present during fall incident review |
Inspection Report
Routine
Census: 64
Deficiencies: 20
Date: Apr 4, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements including resident rights, care and services, infection control, staffing, medication administration, and safety measures.
Findings
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.
Deficiencies (20)
Failed to maintain the dignity of residents by not promptly responding to toileting requests and allowing residents to remain in soiled briefs for extended periods.
Failed to preclude commingling of resident funds with facility funds for multiple residents.
Failed to notify a resident timely regarding Medicaid resource limits and potential loss of eligibility.
Failed to provide written discharge notification to a resident upon discharge.
Failed to complete discharge and death in facility assessments timely for several residents.
Failed to update care plan to reflect smoking supervision and incidents of smoking inside the facility for a resident.
Failed to assist residents with changing briefs in a timely manner after toileting.
Failed to ensure prescribed brace was applied to a resident's contracted hand as ordered.
Failed to implement fall prevention measures including bed positioning, fall mats, and bed cane rails for a resident with a history of falls.
Failed to maintain clean technique and proper infection control when administering feeding tube medications and care, including failure to clean equipment and hand hygiene.
Failed to ensure oxygen tubing and CPAP masks were stored in a sanitary condition and cleaned regularly.
Failed to provide ongoing communication and documentation with dialysis facility regarding resident's dialysis care.
Failed to have sufficient nursing staff on weekends to meet resident care needs.
Failed to ensure Certified Nursing Assistants had competencies to assure resident safety and well-being.
Failed to ensure medications were safely administered to the correct resident, resulting in a resident receiving another resident's medications.
Failed to ensure medications were stored at appropriate temperature, medication room cleanliness, proper labeling of opened medications, and separation of medications and non-medical objects.
Failed to provide timely and complete Tuberculosis (TB) testing for residents as required.
Failed to ensure catheter drainage bags and tubing were not on the floor, posing infection control risks.
Failed to provide pneumococcal and influenza vaccinations to residents or properly document vaccination status.
Failed to provide COVID-19 vaccinations to residents or properly document vaccination status.
Report Facts
Facility census: 64
Deficiency count: 20
Staffing shortages: 20
Staffing shortages: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CMT C | Certified Medication Technician | Named in medication error finding for administering wrong resident's medications |
| CNA H | Certified Nursing Assistant | Named in medication error finding for instructing resident to take medications left at bedside |
| LPN A | Licensed Practical Nurse | Named in multiple findings including medication administration, infection control, and staffing |
| LPN B | Licensed Practical Nurse | Named in medication error finding and infection control |
| CMT B | Certified Medication Technician | Named in infection control and medication administration findings |
| CNA B | Certified Nursing Assistant | Named in infection control and staffing findings |
| LPN C | Licensed Practical Nurse | Named in staffing and medication administration findings |
| DON | Director of Nursing | Named in multiple findings including staffing, infection control, medication administration, and care planning |
| Administrator | Administrator | Named in staffing and medication administration findings |
| ROC | Regional Operations Coordinator | Named in care planning and infection control findings |
Inspection Report
Complaint Investigation
Census: 52
Deficiencies: 2
Date: Mar 11, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding alleged verbal abuse by a Certified Medication Technician (CMT) towards a resident.
Complaint Details
The complaint investigation substantiated that the CMT verbally abused Resident #3 by yelling and using offensive language. The facility took corrective actions including terminating the CMT and providing staff training on abuse and neglect policies.
Findings
The facility failed to protect a resident from verbal abuse by a staff member, evidenced by the CMT yelling and using inappropriate language towards the resident. The facility has policies against abuse and neglect but did not prevent this incident.
Deficiencies (2)
F600 Freedom from Abuse and Neglect: The facility failed to protect one resident from verbal abuse by a Certified Medication Technician who used inappropriate language and was disrespectful during medication administration.
A8023 Develop/Implement Abuse and Neglect Policies: The facility did not develop and implement written policies prohibiting mistreatment, neglect, and abuse of residents, including reporting requirements to appropriate authorities.
Report Facts
Facility census: 52
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Matthew Woods | Administrator | Signed the inspection report and plan of correction |
Inspection Report
Complaint Investigation
Census: 52
Deficiencies: 1
Date: Feb 27, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding verbal abuse of a resident by a Certified Medication Technician (CMT A) on 2/27/24.
Complaint Details
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.
Findings
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.
Deficiencies (1)
Failure to protect a resident from verbal abuse by a staff member who yelled and used inappropriate language.
Report Facts
Residents present: 52
Residents sampled: 6
Date of incident: Feb 27, 2024
Date survey completed: Mar 11, 2024
Date of staff corrective action: Mar 1, 2024
Date of termination: Mar 6, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CMT A | Certified Medication Technician | Named in verbal abuse finding and investigation |
| LPN A | Licensed Practical Nurse | Witness and involved in addressing the incident |
| Maintenance Director | Witnessed and intervened in the incident | |
| Nutritionist | Witnessed the incident and intervened | |
| Housekeeping Manager | Witnessed the incident and reported | |
| Administrator | Facility Administrator | Informed of incident and responsible for termination |
Inspection Report
Routine
Census: 54
Deficiencies: 6
Date: Sep 22, 2023
Visit Reason
The inspection was conducted to evaluate the facility's infection prevention and control program, including employee tuberculosis screening, wound care practices, medication administration, COVID-19 precautions, and compliance with related policies during an outbreak.
Findings
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.
Deficiencies (6)
Failed to properly screen new employees for tuberculosis prior to hire.
Failed to ensure proper infection control practices during wound care for sampled residents.
Medication cart was not kept sanitary and contained personal items and bleach wipes with medications.
Staff did not consistently wear appropriate PPE or masks when caring for COVID-19 positive residents or while in the building.
Doors to rooms with COVID-19 positive residents were left open instead of being kept closed.
Visitors and some staff did not wear masks or wore masks improperly during the outbreak.
Report Facts
Residents census: 54
Employees sampled for TB screening: 10
Employees failed TB screening prior to hire: 8
COVID-19 positive residents: 9
Rooms with isolation carts: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN A | Registered Nurse | Observed performing wound care and medication pass with infection control deficiencies; noted for improper PPE and mask use |
| CMT C | Certified Medication Technician | Observed administering medications to COVID-19 positive resident with PPE deficiencies and medication cart sanitation issues |
| LPN A | Licensed Practical Nurse | Interviewed regarding wound care procedures and infection control practices |
| DON | Director of Nursing | Provided education on COVID-19 protocols; responsible for ensuring compliance with infection control policies |
| CMT B | Certified Medication Technician | Interviewed about COVID-19 education and medication cart responsibilities |
| MDS Coordinator | MDS Coordinator | Interviewed regarding hand hygiene and infection control practices |
| Regional Nurse | Regional Nurse | Observed with improper mask use during outbreak |
Inspection Report
Routine
Census: 54
Capacity: 118
Deficiencies: 17
Date: Sep 22, 2023
Visit Reason
Routine inspection of Jefferson Health Care nursing home to assess compliance with federal and state regulations including resident rights, care planning, medication administration, infection control, and facility safety.
Findings
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.
Deficiencies (17)
Failed to deposit residents' personal funds in excess of $100 in an interest bearing Resident Trust Fund account with market comparable interest.
Failed to ensure resident code status was documented correctly throughout the medical record for four sampled residents.
Failed to complete criminal background checks for three out of ten sampled new staff prior to hire.
Failed to ensure comprehensive Minimum Data Set assessments were completed and submitted timely for three sampled residents.
Failed to ensure quarterly Minimum Data Set assessments were completed and submitted timely for five sampled residents.
Failed to ensure Minimum Data Set assessments were submitted timely for seven sampled residents.
Failed to ensure Minimum Data Set assessments were signed by a Registered Nurse for seven sampled residents.
Failed to develop a baseline care plan that included dialysis for one sampled resident.
Failed to care plan the dental status for one sampled resident and failed to schedule an appointment with an oral surgeon.
Failed to follow physician's orders to complete lab tests for two sampled residents; inaccurate documentation of as needed pain medication for one resident; incomplete weekly wound assessments for one resident; and failure to verify feeding tube placement before medication administration for one resident.
Failed to respond timely to call lights for two sampled residents and failed to provide two baths or showers weekly for three sampled residents.
Failed to complete accuchecks and insulin administration for one sampled resident as ordered.
Failed to ensure two nurses counted narcotics at shift changes; medication carts were left unlocked and unattended; medication refrigerator was not maintained at correct temperature; no backup key for medication safe; expired medications not disposed; and opened medications not dated.
Failed to properly screen new employees for tuberculosis prior to hire for eight out of ten sampled employees.
Failed to ensure staff used proper infection control practices during wound care, ensure visitors and staff wore appropriate PPE and masks, maintain COVID-19 positive rooms properly, keep medication cart sanitary, and ensure hand hygiene during medication pass.
Failed to post nurse staffing information daily in a prominent place accessible to residents and visitors.
Failed to provide or obtain restorative therapy services for one sampled resident.
Report Facts
Residents affected: 19
Facility census: 54
Total capacity: 118
Employees hired: 10
Narcotic count sheet opportunities: 100
Narcotic count sheet missing signatures: 26
Medication refrigerator temperature checks: 3
Expired medications: 8
Inspection Report
Complaint Investigation
Census: 49
Deficiencies: 1
Date: Jun 6, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding alleged resident-to-resident abuse at Jefferson Health Care.
Complaint Details
The complaint investigation was substantiated. Resident #1 was observed and reported to have touched Resident #2's left breast inappropriately. Multiple interviews with staff, residents, and the administrator confirmed the incident.
Findings
The facility failed to ensure a sampled resident was free from resident-to-resident abuse when one resident touched another resident's left breast. The incident was substantiated based on interviews and review of facility records.
Deficiencies (1)
F 600 Freedom from Abuse, Neglect, and Exploitation: The facility failed to prevent resident-to-resident abuse when Resident #1 touched Resident #2's left breast without consent.
Report Facts
Facility census: 49
Inspection Report
Complaint Investigation
Census: 49
Deficiencies: 1
Date: Jun 6, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding an incident of resident-to-resident abuse where Resident #1 touched Resident #2's left breast on 6/5/2023.
Complaint Details
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.
Findings
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.
Deficiencies (1)
Failure to protect residents from resident-to-resident abuse when Resident #1 touched Resident #2's left breast.
Report Facts
Residents present: 49
BIMS score: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CMT A | Certified Medication Technician | Witnessed the abuse incident and reported it to nursing staff and Director of Nursing |
| LPN A | Licensed Practical Nurse | Received report from CMT A and directed reporting to Director of Nursing |
| Administrator | Notified of the incident, believed the incident was abuse, and involved law enforcement | |
| Law Enforcement Officer A | Interviewed residents and Administrator regarding the abuse incident | |
| DON | Director of Nursing | Received reports and statements regarding the abuse incident and took corrective actions |
Inspection Report
Plan of Correction
Census: 49
Deficiencies: 2
Date: Dec 14, 2022
Visit Reason
The inspection was conducted to investigate deficiencies related to pharmacy services, medication procedures, and controlled substance management at Jefferson Health Care.
Findings
The facility failed to follow procedures ensuring accurate acquiring, receiving, and dispensing of controlled substances, specifically Oxycodone 5 mg. Discrepancies in medication counts and delivery documentation were found, involving Resident #500 and staff members, leading to an investigation and staff suspension.
Deficiencies (2)
F755 Pharmacy Services: The facility failed to ensure accurate acquiring, receiving, and dispensing of Oxycodone 5 mg, evidenced by discrepancies in medication counts and delivery records for Resident #500.
A4013 Policies/Procedures-Operational: The facility did not develop adequate policies and procedures to ensure residents' health and safety, referencing the F755 deficiency.
Report Facts
Facility census: 49
Medication tablets discrepancy: 30
Medication tablets counted: 60
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN B | Licensed Practical Nurse | Involved in medication delivery and investigation of discrepancies |
| LPN A | Licensed Practical Nurse | Notified Director of Nursing about medication discrepancy |
| Director of Nursing | Interviewed regarding medication discrepancy and investigation | |
| Administrator | Interviewed regarding medication discrepancy and investigation | |
| Pharmacy Operations Manager | Provided information on medication orders and delivery procedures |
Inspection Report
Routine
Census: 48
Deficiencies: 17
Date: Oct 18, 2022
Visit Reason
The inspection was a routine survey to assess compliance with regulatory requirements including resident rights, notice of Medicare coverage, abuse prevention, resident assessments, care planning, activities, hospice care, pressure ulcer care, medication administration, infection control, employee screening, and food and nutrition services.
Findings
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.
Deficiencies (17)
Failed to ensure code status was consistent and honored for sampled residents.
Failed to provide Notice of Medicare Provider Non-Coverage and Skilled Nursing Facility Advanced Beneficiary Notice to sampled residents discharged from Medicare Part A.
Failed to complete required criminal background checks, nurse aide registry checks, and employee disqualification list checks prior to hire for sampled staff.
Failed to complete quarterly Minimum Data Set assessment for a sampled resident.
Failed to complete death in facility tracking form and discharge assessment for sampled residents.
Failed to develop comprehensive care plans addressing residents' needs including dementia, high risk medications, depression, insomnia, vision needs, and preferences.
Failed to provide ongoing activity programs based on residents' preferences and failed to document participation.
Failed to ensure documentation of all hospice visits and care plans for a sampled resident.
Failed to complete weekly skin assessments, document findings, and describe wound for a sampled resident with pressure ulcers.
Failed to provide nurse aides competency skills training and competency validation.
Failed to ensure nurse aide certification within four months of training completion for one nurse aide.
Medication errors including failure to prime insulin pen, administering insulin more than one hour before meal, and administering bedtime medication at breakfast time.
Failed to keep medication carts locked when unattended, maintain resident privacy with open MAR, monitor medication refrigerator temperatures, and maintain temperature logs.
Failed to employ sufficient food and nutrition staff to safely and effectively carry out functions.
Failed to maintain sanitary food preparation areas and equipment, properly document food temperatures, maintain cutting boards and utensils in good condition, and properly label food items.
Failed to implement a comprehensive infection prevention and control program including water management for Legionella, employee tuberculosis screening, hand hygiene compliance, wound and pericare handwashing, insulin pen sanitation, and resident tuberculosis testing.
Failed to provide or offer pneumococcal vaccines and document refusals or education for sampled residents.
Report Facts
Facility census: 48
Medication error rate: 10
Number of meals prepared: 35
Number of mechanically soft meals: 11
Number of soft puree meals: 2
Food temperature recordings: 46
Employee hires missing CBC: 7
Employee hires missing NA registry check: 7
Employee hires missing EDL check: 6
Employee hires missing TB screening: 7
Inspection Report
Plan of Correction
Census: 57
Deficiencies: 4
Date: Jul 13, 2022
Visit Reason
The inspection was conducted to assess compliance with pharmacy services and medication administration regulations at Jefferson Health Care, including review of deficiencies and corrective actions.
Findings
The facility failed to provide accurate medication reconciliation and administration for sampled residents, resulting in missed doses and medication errors. Deficiencies were cited related to pharmacy services, medication errors, and record keeping.
Deficiencies (4)
F755 Pharmacy Services: The facility failed to reconcile controlled substance medications accurately, resulting in discrepancies and potential for abuse. The facility census was 57 residents at the time of inspection.
F760 Residents are Free of Significant Medication Errors: The facility failed to ensure two sampled residents were free from significant medication errors by not administering medications as ordered.
A4060 Medication Errors/Adverse Reactions Reported: The facility failed to report medication errors and adverse reactions immediately as required, resulting in a Class II deficiency.
A4070 Med Released/Received Record: The facility failed to maintain proper records of medication released to residents or families, resulting in a Class III deficiency.
Report Facts
Facility census: 57
Missed medication doses: 9
Missed medication doses: 9
Missed medication doses: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Named in medication reconciliation review and plan of correction |
| Certified Medication Technician (CMT) A | Certified Medication Technician | Interviewed regarding medication reorder and delivery |
| Registered Nurse (RN) A | Registered Nurse | Interviewed regarding medication delivery and reorder process |
| Certified Medication Technician (CMT) B | Certified Medication Technician | Interviewed regarding medication delivery schedule |
| Physician | Physician | Interviewed regarding medication orders and facility pharmacy issues |
| Administrator | Administrator | Signed the plan of correction |
Inspection Report
Plan of Correction
Census: 56
Deficiencies: 1
Date: Feb 2, 2022
Visit Reason
The document is a Statement of Deficiencies and Plan of Correction for Jefferson Health Care following a survey completed on 02/02/2022. It addresses past noncompliance related to resident rights and dignity.
Findings
The facility failed to ensure residents were treated with dignity and respect, as evidenced by multiple residents reporting rude behavior and poor medication management by Licensed Practical Nurse (LPN) A. The facility census was 56 residents at the time of the survey.
Deficiencies (1)
F 550 Resident Rights: The facility failed to ensure residents were treated with dignity and respect, demonstrated by rude behavior and poor medication management by LPN A toward multiple residents.
Report Facts
Facility census: 56
Number of sampled residents: 14
Number of residents with dignity issues: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN A | Licensed Practical Nurse | Named in multiple findings related to rude behavior and medication management issues |
| Director of Nurses | DON | Notified of past noncompliance and involved in investigation |
| Certified Medication Technician A | CMT | Interviewed regarding resident complaints about LPN A |
| Administrator | Interviewed regarding LPN A's behavior and suspension | |
| LPN B | Licensed Practical Nurse | Interviewed about night shift and resident complaints |
| Nursing Assistant | NA | Reported on interactions with residents and LPN A |
Inspection Report
Routine
Deficiencies: 0
Date: Oct 26, 2021
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control survey was conducted to assess compliance with relevant federal regulations and CDC recommended practices.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness and with CMS and CDC recommended practices for COVID-19 infection control.
Inspection Report
Routine
Deficiencies: 0
Date: Sep 27, 2021
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control Survey was conducted to assess compliance with relevant federal regulations and CDC recommended practices.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness and with CMS and CDC recommended practices for COVID-19 infection control.
Inspection Report
Follow-Up
Census: 55
Deficiencies: 1
Date: Jul 29, 2021
Visit Reason
The visit was a follow-up inspection to address a past non-compliance related to resident rights and dignity after an incident involving a Certified Medication Technician (CMT) spitting on a resident.
Findings
The facility failed to ensure one sampled resident was treated with respect and dignity during an incident involving spitting between the resident and a staff member. The facility conducted a thorough investigation, terminated the involved staff member, and implemented staff re-education on dignity, abuse, and neglect.
Deficiencies (1)
F 550 Resident Rights: The facility failed to ensure one resident was treated with respect and dignity when a Certified Medication Technician spat on the resident and the resident spat back. The facility identified the violation and terminated the staff member involved.
Report Facts
Facility census: 55
Number of residents sampled: 3
Number of residents signing statements: 18
Court date: Oct 21, 2021
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CMT A | Certified Medication Technician | Named in the incident involving spitting on a resident and subsequent termination |
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Oct 1, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control Survey was conducted to assess compliance with relevant regulations and CDC recommended practices.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness and with CMS and CDC recommended practices for COVID-19 infection control.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Sep 3, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control Survey was conducted to assess compliance with relevant regulations and CDC recommended practices.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness and with CMS and CDC recommended practices for COVID-19 infection control.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: May 22, 2020
Visit Reason
A COVID-19 focused emergency preparedness and infection control survey was conducted to assess compliance with relevant CMS and CDC guidelines.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness and with CMS and CDC recommended practices for COVID-19 infection control.
Inspection Report
Plan of Correction
Census: 51
Deficiencies: 5
Date: Dec 18, 2019
Visit Reason
The inspection was conducted to assess compliance with federal regulations regarding resident care, including accuracy of assessments, psychotropic medication use, and dental services at Jefferson Health Care.
Findings
The facility failed to ensure accurate Minimum Data Set (MDS) assessments for residents, proper use and documentation of psychotropic medications, and adequate provision of routine and emergency dental services. Deficiencies were identified related to pressure ulcer assessments, psychotropic medication orders, and dental care access.
Deficiencies (5)
F641 Accuracy of Assessments. The facility failed to ensure the accuracy of MDS assessments for sampled residents, including incorrect documentation of pressure ulcers and resident weight.
F758 Free from Unnecessary Psychotropic Medications. The facility failed to ensure PRN anxiolytic orders were limited to 14 days and lacked proper documentation of clinical necessity for psychotropic medication use in one resident.
F791 Routine/Emergency Dental Services. The facility failed to ensure routine and emergency dental services were provided to residents, including timely referrals and documentation of dental care.
A4074 Nursing Care per Resident Condition. Each resident did not receive personal attention and nursing care consistent with current acceptable nursing practice, as evidenced by deficiencies referenced in F758 and F791.
A4099 Social Service Program. The facility failed to designate a staff member responsible for the social services program capable of identifying and meeting residents' social and emotional needs.
Report Facts
Facility census: 51
Deficiencies cited: 5
Inspection Report
Life Safety
Census: 51
Capacity: 120
Deficiencies: 7
Date: Dec 18, 2019
Visit Reason
The inspection was a Life Safety Code survey conducted to assess compliance with fire safety and emergency preparedness regulations.
Findings
The facility was found to have multiple deficiencies related to fire safety systems including means of egress, emergency lighting, exit signage, fire alarm system installation and maintenance, HVAC ventilation issues, and electrical equipment safety. The emergency preparedness portion had no deficiencies.
Deficiencies (7)
K211 Means of Egress - General: The facility failed to provide a functioning locking device release on an egress door, affecting approximately 45 residents and staff. The door did not open or disengage the alarm after pushing for over 30 seconds.
K291 Emergency Lighting: The facility failed to itemize emergency lighting devices and statuses, and lacked a facility generator for emergency lighting. Batteries were used but documentation was incomplete.
K293 Exit Signage: The facility failed to ensure three directional exit signs were illuminated and visible during power outages or emergencies, affecting approximately 20 residents.
K341 Fire Alarm System - Installation: The facility failed to install and program a complete fire alarm system that included a silencing feature for the audible alarm, causing potential confusion and safety risks.
K345 Fire Alarm System - Testing and Maintenance: The facility failed to provide complete documentation of annual fire alarm inspections and testing as required by NFPA standards.
K521 HVAC: The facility failed to ensure proper ventilation in resident rooms and utility rooms, causing strong odors and potential exposure to harmful fumes affecting two residents.
K920 Electrical Equipment - Power Cords and Extension Cords: The facility failed to maintain electrical equipment properly, including misuse of power strips and extension cords in patient care areas, affecting 25 residents.
Report Facts
Residents affected: 45
Residents affected: 20
Residents affected: 25
Facility census: 51
Licensed capacity: 120
Inspection Report
Plan of Correction
Census: 61
Deficiencies: 12
Date: Nov 15, 2018
Visit Reason
The document is a Plan of Correction submitted by Jefferson Health Care Center following a survey conducted on 11/15/2018. It addresses deficiencies cited during the inspection.
Findings
The facility was found deficient in multiple areas including Medicaid/Medicare coverage notices, transfer/discharge notices, baseline care plans, medication administration and storage, infection control, food safety, and use of mechanical lifts. Deficiencies affected residents' rights, care planning, medication safety, and infection prevention.
Deficiencies (12)
F582 Medicaid/Medicare Coverage/Liability Notice: The facility failed to provide Skilled Nursing Facility Advanced Beneficiary Notices (SNFABN) for three supplemental residents discharged from Medicare Part A services while remaining in the facility.
F623 Notice Requirements Before Transfer/Discharge: The facility failed to notify residents and/or their representatives in writing of transfers or discharges for two sampled residents, and failed to provide timely notices at least 30 days prior to transfer or discharge.
F625 Notice of Bed Hold Policy Before/Upon Transfer: The facility failed to provide written notice of the bed-hold policy to residents or their representatives at the time of transfer or discharge for five sampled residents.
F655 Baseline Care Plan: The facility failed to develop and implement baseline care plans within 48 hours of admission for four sampled residents, and failed to provide summaries of baseline care plans to residents or representatives.
F657 Care Plan Timing and Revision: The facility failed to develop comprehensive care plans within 7 days after assessments and failed to revise care plans timely for four sampled residents.
F658 Services Provided Meet Professional Standards: The facility failed to accurately reflect pain medication administration and document pain assessment for one sampled resident.
F689 Free of Accident Hazards/Supervision/Devices: The facility failed to ensure mechanical lifts were used properly to transfer residents, resulting in unsafe transfers for two sampled residents.
F760 Residents are Free of Significant Medication Errors: The facility failed to ensure residents were free from significant medication errors by incorrectly administering insulin to one sampled resident.
F761 Label/Store Drugs and Biologicals: The facility failed to store medications correctly in medication carts and failed to secure sharps containers for three sampled medication carts.
F812 Food Procurement, Store, Prepare, Serve-Sanitary: The facility failed to maintain sanitary kitchen utensils and equipment, and failed to employ proper hand hygiene to prevent foodborne illnesses.
F814 Dispose Garbage and Refuse Properly: The facility failed to properly contain waste in dumpsters and maintain cleanliness of the kitchen perimeter, potentially affecting residents.
F880 Infection Prevention & Control: The facility failed to use appropriate infection control measures to prevent transmission of communicable diseases and failed to provide adequate in-service education to staff.
Report Facts
Facility census: 61
Sampled residents: 15
Medication administration: 13
Medication administration: 9
Inspection Report
Life Safety
Census: 61
Capacity: 120
Deficiencies: 10
Date: Nov 15, 2018
Visit Reason
An emergency preparedness portion of a Life Safety Code Survey was conducted to assess compliance with federal, state, and local emergency preparedness and fire safety requirements.
Findings
The facility failed to have a comprehensive Emergency Preparedness plan including required contact information, provisions for residents with special needs, and training procedures. Deficiencies were also found in the fire alarm system installation, sprinkler system protection, fire extinguisher maintenance, fire drill documentation, smoking regulations enforcement, and electrical equipment safety.
Deficiencies (10)
E001 Emergency Preparedness plan lacked state and federal agency contact numbers, provisions for residents with special needs, weather contingency measures, and staff training procedures.
K341 Fire alarm system installation was deficient, lacking initiating devices in the kitchen to provide effective fire warning coverage.
K351 Sprinkler system failed to ensure protection under eaves greater than four feet deep, affecting multiple smoke zones.
K353 Sprinkler system maintenance and testing records were incomplete, and spray patterns of sprinkler heads were obstructed.
K355 Portable fire extinguishers in the kitchen were improperly installed and lacked documentation of annual inspections.
K500 Facility failed to provide documentation for a plumbing backflow preventer inspection within the last two years.
K712 Fire drills were not thoroughly documented with missing dates, times, and confirmation of successful fire alarm transmission.
K741 Smoking regulations were not enforced; cigarette butts were found in trash receptacles and on the ground, and proper signage and self-closing devices were lacking.
K900 Facility failed to provide proper education and training for the Maintenance Director, affecting staff performance in smoke zones.
K920 Electrical equipment was improperly used with surge protectors and extension cords, creating potential fire hazards in multiple smoke zones.
Report Facts
Facility census: 61
Total licensed capacity: 120
Number of smoke zones affected: 8
Number of smoke zones with sprinkler deficiencies: 5
Number of fire drills reviewed: 12
Number of fire drills with missing confirmation: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Ruby Johnson | Administrator | Named in relation to emergency preparedness deficiency and plan of correction |
| Maintenance Director | Interviewed regarding fire alarm system, sprinkler system, fire extinguisher maintenance, fire drills, and electrical equipment deficiencies |
Inspection Report
Complaint Investigation
Census: 62
Deficiencies: 10
Date: Feb 23, 2018
Visit Reason
The inspection was conducted due to complaint investigations regarding failure to properly check the Nurse Aide Registry prior to hiring, failure to notify residents and representatives before transfers or discharges, failure to notify about bed-hold policies, and other regulatory compliance issues.
Complaint Details
The complaint investigation substantiated multiple deficiencies related to employee background checks, resident transfer notifications, bed-hold policies, care planning, professional standards, medication management, and infection control.
Findings
The facility was found noncompliant with multiple regulatory requirements including failure to check the Nurse Aide Registry for new hires, failure to notify residents and representatives of transfers or discharges, failure to notify about bed-hold policies, failure to develop comprehensive care plans, failure to meet professional standards in services, medication management deficiencies, and infection control issues.
Deficiencies (10)
F606: The facility failed to check the Nurse Aide Registry prior to hiring new employees as required by regulation.
F623: The facility failed to notify residents and their representatives in writing of transfers or discharges, including reasons and appeal rights, and failed to notify the Ombudsman as required.
F625: The facility failed to notify residents and representatives in writing of the bed-hold policy before transfers to hospital or therapeutic leave.
F656: The facility failed to develop and implement comprehensive person-centered care plans for residents, including measurable objectives and timeframes.
F658: The facility failed to ensure services met professional standards, including proper setup and monitoring of low air loss mattresses and alarms.
F685: The facility failed to assist residents in obtaining hearing services and failed to document hearing evaluations and plans of care.
F755: The facility failed to ensure proper pharmacy services, including accurate narcotic counts and medication record keeping.
F758: The facility failed to ensure psychotropic medications were used appropriately and discontinued when no longer needed.
F761: The facility failed to ensure medications were secure, properly labeled, and not left unattended, and failed to ensure expired medications were destroyed or returned.
F780: The facility failed to follow CDC guidelines for infection prevention and control, including screening for tuberculosis and maintaining a safe environment.
Report Facts
Facility census: 62
Sampled residents: 16
Sampled employees: 4
Missing signatures: 6
Inspection Report
Life Safety
Census: 61
Capacity: 120
Deficiencies: 5
Date: Feb 23, 2018
Visit Reason
The inspection was conducted to assess compliance with the 2012 edition of the Life Safety Code of the National Fire Protection Association, focusing on fire drills, fire door maintenance, electrical systems, and emergency preparedness.
Findings
The facility failed to meet several Life Safety Code requirements including incomplete and untimely fire drills, lack of annual inspection and testing of fire doors, inadequate electrical system maintenance and testing, and missing documentation for surge protectors. The emergency preparedness portion of the survey did not result in deficiencies.
Deficiencies (5)
K712 Fire Drills: The facility failed to conduct quarterly fire drills on varying dates for all shifts and lacked documentation of fire alarm transmission and fire department contact.
K761 Maintenance, Inspection & Testing - Doors: The facility did not annually inspect and test fire doors and smoke barrier corridor doors, risking fire and smoke spread.
K914 Electrical Systems - Maintenance and Testing: The facility did not assess electrical receptacles at resident bed locations for integrity, grounding, polarity, and retention force.
K918 Electrical Systems - Essential Electric System Maintenance and Testing: The facility failed to maintain and test the electrical main and circuit breakers annually as required.
K921 Electrical Equipment - Testing and Maintenance: The facility failed to ensure surge protectors were tested and documented, risking electrical injuries and fire hazards.
Report Facts
Facility census: 61
Licensed capacity: 120
Fire drills missing: 5
Fire drills reviewed: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jennifer A. Knight | Administrator | Signed the report and plan of correction; mentioned as Administrator monitoring compliance |
| Maintenance Supervisor | Interviewed regarding fire drills and electrical inspection deficiencies |
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