Jamestown Health and Rehabilitation

In the surveyor’s words

From the most serious findings on record at Jamestown Health and Rehabilitation, in the surveyor’s own words.

• Actual harm, isolatedF689May 12, 2022

  Based on staff interview, clinical record review, facility documentation review, and in the course of a complaint investigation, the facility staff failed to mitigate a fall hazard for 1 Resident (Resident #135) and failed to utilize a mechanical lift during a transfer from the wheelchair to the bed for 1 resident (Resident #32) in a sample of 33 Residents, resulting in harm for both Residents. The findings included: 1) Resident #135 fell while left alone in the shower room on 2-4-22 at 5:45 a.m., resulting in a fractured upper femur (hip area). This is harm. Resident #135 was sent out to the emergency roiagnom on [DATE] after the fall and fracture, and returned on 2-14-22 after a 10 day stay. […]

• No harm, potential for more than minimal, widespreadF882Mar 31, 2022

  Based on observation, staff interview, and facility documentation review, the facility staff failed to employ a certified infection preventionist to mitigate the spread of COVID-19. There was no Certified infection preventionist for the facility. The findings included: On 3/28/2022 at approximately 1:00 P.M., The Administrator, and Director of Nursing (DON) were interviewed. When asked who the Infection Preventionist was, the Administrator stated that the Assistant Director of Nursing (ADON) was responsible. The Administrator also stated that the Assistant Director of Nursing (ADON) keeps track of all vaccinations, and went on to say it was the DON's first day in the facility. On 3/31/22 at 10:00 A.M. […]

• No harm, potential for more than minimal, patternF577May 12, 2022

  Based on observation, Resident interview, and staff interview, the facility failed to post survey results in a place readily accessible to Residents. The findings included: On 05/11/2022 at approximately 10:30 A.M., a resident Council meeting was conducted. There were six residents in attendance. When the group was asked if they knew where the survey results were located, all of the residents in the meeting indicated they did not know where the survey results were located. On 05/11/2022 11:04 A.M., the binder containing the survey results was observed in a glasstop display table in the front lobby. The glass top display was situated in the corner with a chair and a side table on each side. […]

• No harm, potential for more than minimal, patternF883May 12, 2022

  Based on staff interview, facility documentation review, and clinical record review, the facility staff failed to implement their immunization policy and ensure each Resident is offered influenza and pneumococcal immunization, for 3 Residents (Resident #9, #81, and #287), in a sample of 5 Residents reviewed for immunizations. The findings included: On 5/10/22, clinical record reviews were conducted for the sampled Residents with regards to immunization for flu and pneumonia. This review revealed the following: 1. In Resident #9 electronic health record (EHR) there was no documentation with regards to the pneumonia vaccine status of Resident #9. There was evidence that Resident #9 had refused the flu vaccine for the 2020-2021 flu season. […]

• No harm, potential for more than minimal, patternF886May 12, 2022

  Based on staff interviews and facility documentation review, the facility staff failed to conduct routine COVID-19 testing in accordance with the CDC recommendations for 5 facility staff (RN D, CNA B, CNA D, LPN D and LPN E), who were not up-to-date with COVID vaccinations, in a survey sample of 5 staff reviewed for COVID testing. The findings included: The facility staff failed to conduct routine testing of facility staff who were not fully vaccinated for COVID-19 as per the guidance from CDC and the facility policy. […]