Jefferson City Manor Care Center

In the surveyor’s words

From the most serious findings on record at Jefferson City Manor Care Center, in the surveyor’s own words.

• Actual harm, isolatedF760Nov 27, 2023

  Based on observation, interview, and record review, facility staff failed to ensure the residnet was free from a significant medication error when staff failed to administer of one resident's (Resident #1) Metolazone (a diuretic medication used to treat high blood pressure and edema) and Torsemide (a diuretic medication used to treat edema due to congestive heart failure (CHF), kidney disease, or liver disease) as directed by the physician and failed to notify the resident's physician the medication was not available to be administer which resulted in the resident being admitted to the hospital with acute chronic hypoxic respiratory failure (not enough oxygen in the blood), mild pulmonary edema with pleural effusion (fluid collected inside and outside of the lungs), and chronic kidney… […]

• Actual harm, isolatedF686Jan 30, 2023

  Based on observation, interview, and record review, facility staff failed to provide care consistent with professional standards of practice to promote the prevention of pressure ulcer (PU) development for one resident (Resident #52) after staff identified the resident was at risk for PUs. Additionally, staff failed to obtain a physician ordered treatment for an unstageable wound to the resident's coccyx, from 11/16/22 to 12/22/22, more than 30 days after the start of the PU, failed to obtain a physician ordered treatment for an unstageable PU to the resident's left hip discovered on 12/31/22, failed to follow the resident's plan of care to prevent additional pressure injuries (PI)s and promote the healing of PUs. […]

• No harm, potential for more than minimal, widespreadF838Apr 7, 2026

  Based on interview and record review, facility staff failed to conduct and document an annual facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies as required. The facility census was 70.1. Review of the facility's Facility Assessment policy, revised October 2018, showed the facility assessment is conducted annually to determine and update the capacity to meet the need of and competently care for the residents during day-to-day operations. Determining our capacity to meet the needs of and care for the residents during emergencies is included in this assessment. […]

• No harm, potential for more than minimal, widespreadF812Jun 7, 2024

  Based on observation, interview and record review, the facility staff failed to store food in a manner to prevent potential contamination and out-dated use. Facility staff failed to maintain the kitchen equipment and surfaces in a sanitary manner to prevent the growth of bacteria and cross-contamination. Facility staff failed to maintain and serve food at temperatures adequate to prevent food borne illness. The facility staff failed to ensure the ice machine, used to supply ice to residents, drained through an air gap to prevent cross-contamination. These failures have the potential to affect all residents. The facility census was 72. 1. Review of the facility's policies showed the facility did not provide a policy for food dating and storage. 2. […]

• No harm, potential for more than minimal, widespreadF812Jan 30, 2023

  Based on observation, interviews, and record review, the facility staff failed to ensure the ice bin drained through an air gap. Facility staff failed to maintain the ceiling over the food preparation and service area in a clean and sanitary manner. This had the potential to affect all facility residents. The census was 80. 1. Review of the facility's policies showed the facility did not have a policy which addressed the inspection and maintenance of the ice machine. Observation on 1/26/23 at 1:00 P.M., showed the ice machine, located in the kitchen, did not drain through an air gap. […]