Jacob's Creek Nursing and Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Jacob's Creek Nursing and Rehabilitation Center, in the surveyor’s own words.

• Immediate jeopardy, patternF835Jan 11, 2022

  Based on observation, record review, resident, staff and physician interviews, the facility's administration failed to evaluate the resident population on the memory care unit for the need to have a functional call system in place to alert staff to immediate needs for 8 of 8 (resident #29, #46, #35, #14, #69, #87, #89 and #71) residents with severe to no cognitive impairment that had the physical and cognitive ability to use the call system on the memory care unit (500 and 600 hall). Failure to allow residents to call for assistant in an emergency is likely to cause serious injury, serious harm, or death. […]

• Immediate jeopardy, patternF919Jan 11, 2022

  Based on observation, record review, resident, staff, and physician interviews the facility failed to have a functional call system in place for 8 of 8 (resident #29, #46, #35, #14, #69, #87, #89 and #71) residents who had the physical and cognitive ability to use the call system on the memory care unit (500 and 600 hall). Failure to allow residents to call for assistant in an emergency is likely to cause serious injury, serious harm, or death. Immediate Jeopardy began on 1/2/2022 when it was observed that residents on the memory care unit with the cognitive and physical ability to use the call system did not have a functional call system in the residents' rooms and they did not have an alternate means to call for assistance. […]

• Immediate jeopardy, isolatedF600Sep 18, 2024

  Based on observations, record review, and resident, physician, nurse practitioner and staff interviews the facility failed to protect a resident's right to be free from physical abuse. Resident #123 was observed sitting on a black container behind Resident #100 with his left hand around Resident 100's neck and his right arm covered around his left arm. Resident #100 was leaning forward and crying, and her face was blue. Resident #100 continued to cry after the residents were separated. A skin assessment completed after the incident revealed Resident #100 had redness on her cheeks and petechiae (tiny spots of bleeding under the skin) on the front part of her neck. The abuse occurred for 1 of 3 sampled residents reviewed for protection from abuse (Resident #100). […]

• No harm, potential for more than minimal, patternF695Sep 18, 2024

  Based on observations, record reviews and staff interviews, the facility failed to post cautionary signage outside the resident's room to indicate supplemental oxygen (O2) was in use for 7 of 7 residents reviewed for respiratory care (Resident #109; Resident #79; Resident #114; Resident #70; Resident #51; Resident #343; and Resident #32). The findings included: The facility's policy on Oxygen Therapy (Reviewed Date 4/15/24) indicated its objective was, To administer oxygen in conditions in which insufficient oxygen is carried by the blood to the tissues. The procedures specified in this policy included #2 (of 7) which read, Place sign Oxygen is use [typed in capital letters] outside the room of the resident. 1-a. […]

• No harm, potential for more than minimal, patternF812Sep 18, 2024

  Based on record review, observation and staff interviews, the facility failed to label and date food stored for use in a nourishment room refrigerator and freezers and failed to date opened nutritional supplements in 2 of 2 nourishment refrigerators reviewed for food storage (100 hallway and 500 hallway nourishment room). These practices had the potential to affect food served to residents. Findings included: a. On 9/3/24 at 9:55 AM, an observation of the nourishment room freezer (100 hallway nourishment room), revealed two opened 2.5-pounds (lbs.) bag of frozen smoothie mix. These bags were not labeled or dated. During an interview on 9/3/24 at 9:55 AM, the Dietary Manager stated she was unsure whom the bags belonged to. […]