Jefferson Community Health & Life Gardenside

In the surveyor’s words

From the most serious findings on record at Jefferson Community Health & Life Gardenside, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF732Sep 16, 2021

  Based on record review and staff interview, the facility failed to update the staff posting with the total number and actual hours worked each shift for Registered nurses, Licensed Practical Nurses and Nurse Aides. This had the potential to inaccurately inform all residents that resided in the building and visitors of the facility's staffing. The facility census was 27. Findings are: Review of the staff posting from 9/1/21 through 9/14/21 lacked the required posting of total and actual hours worked by each staff type. An interview with the Director of Nursing on 9/15/21 at 2:28 PM confirmed the total number of hours worked were not documented on the daily staff postings and confirmed the hours worked were not updated to reflect the actual number of hours worked by each discipline.

• No harm, potential for more than minimal, widespreadF812Sep 16, 2021

  Licensure Reference Number 175 NAC 12-006.11C Based on observation and interview, the facility failed to maintain the cleanliness and condition of equipment as evidenced by the presence of dust and grease on the top of the steamer, oven, shelf above the stove top, hard water and lime buildup on the tray and wire rack of the ice machine. The facility failed to ensure that dishes were completely dry prior to putting them away. This had the potential to affect all residents that consumed food and fluids from the facility kitchen. The facility census was 27. Findings are: A. Observation on 09/13/21 between 9:05 - 09:30 AM revealed a fan in the dishwashing room on top of a wire rack. The fan was on and positioned toward the clean area of the dish washer unit where clean dishes were present. […]

• No harm, potential for more than minimal, patternF689Nov 13, 2024

  Licensure Reference Number 175 NAC 12-006.09D7b Based on interview and record review; the facility failed to conduct a thorough investigation to determine the root-cause of falls and failed to develop and implement effective interventions to minimize and/or prevent falls for 3 (Residents 5, 16, and 18) of 3 sampled residents. The facility census was 32. Findings are: Review of the facility Fall Assessment policy, updated 2/2023, revealed the following: -Interventions for residents at risk for falls will be found in the care plan and are specific for that resident. -The Quality Improvement Coordinator will be responsible for trending falls/looking for patterns. This will be done by the following criteria: place of fall, time of fall, day of week of fall, injuries vs. […]

• No harm, potential for more than minimal, isolatedF609Jan 8, 2025

  Licensure Reference Number 175 NAC 12-006.02(H) Based on record review and interview; the facility failed to report an incident related to elopement for 1 (Resident 1) of 3 sampled residents. This had the potential to affect 10 residents identified as at risk for elopement. The facility census was 31. Findings are: A record review of the facility policy Missing Resident revised on 9/19/24, revealed the following: -Elopement is defined as an event in which a resident who needs supervision leaves a safe area without supervision. -5. […]

• No harm, potential for more than minimal, isolatedF610Jan 8, 2025

  Licensure Reference Number 175 NAC 12-006.02(H) Based on record review and interview; the facility failed to investigate an incident related to elopement for 1 (Resident 1) of 3 sampled residents. This had the potential to affect 10 residents identified as at risk for elopement. The facility census was 31. Findings are: A record review of the facility policy Missing Resident revised 9/19/24, revealed the following: -Elopement is defined as an event in which a resident who needs supervision leaves a safe area without supervision. -4. The Charge Nurse will complete an incident report and forward it to the Director of Nursing (DON). -5. […]