Jefferson County Nursing Home

In the surveyor’s words

From the most serious findings on record at Jefferson County Nursing Home, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF700Jan 25, 2024

  Based on observation, staff interview, record review and service manual review the facility failed to assess residents for the risk of entrapment, obtain informed consent, and conduct routine preventative maintenance per the manufacturer's recommendations/specifications for bed rails for five (5) of fourteen (14) sampled residents. (Resident #4, #6, #28, #29 and #39) Findings Include: Observations of resident rooms on 1/23/24 from 10:00 AM to 12:17 PM, revealed Residents #4, #6, #28, #29, and #39 had beds that were the brand name of Basic American Matrix 709 Matrix II and had bilateral quarter (1/4) length bed rails. […]

• No harm, potential for more than minimal, isolatedF656Jul 30, 2026

  Based on observation, interview, record review, and facility policy review, the facility failed to replace an enteral feeding syringe daily as ordered and care planned for one (1) of four (4) resident reviewed for enteral feedings. Resident #9. Findings Include:Record review of the facility policy Comprehensive Care Plan Policy with an effective date of January 2020 revealed, . [NAME] County Nursing Home shall develop, implement, evaluate, and revise an individualized care plan for every resident .Record review of the Care Plan Report revealed Focus: The resident requires tub feeding per peg tube.Interventions/Task.Change enteral syringe daily on night shift.On 7/27/26 at 11:20 AM, Resident #9 was observed in bed receiving Isosource enteral formula at 50 milliliters per hour. […]

• No harm, potential for more than minimal, isolatedF693Jul 30, 2026

  Based on observation, interview, record review, and policy review, the facility failed to ensure a resident with a feeding tube received appropriate treatment and services, as evidenced by failure to replace an enteral feeding syringe daily as ordered for one (1) of four (4) residents reviewed for enteral feeding. Resident #9.Findings Include:A record review of the facility policy, Policy and Procedure: Percutaneous Endoscopic Gastrostomy (PEG) and Gastrostomy Management with a review date of January 2026 revealed, .To establish standardized procedure for the safe care, effective and individualized eternal nutrition therapy for residents requiring PEG or Gastrostomy (G)-tubes .During an observation on 7/27/26 at 11:20 AM, Resident #9 was observed in bed receiving Isosource enteral formula… […]

• No harm, potential for more than minimal, isolatedF880Jul 30, 2026

  Based on observation interview, facility policy review, and record review, the facility failed to follow infection prevention guidelines for one (1) of one (1) residents observed for catheter care. Resident # 4Findings include :A record review of facility policy titled Catheter Care for Male Policy, undated revealed, It is the policy of this facility to provide catheter care to prevent infection of the resident's urinary tract .A record review of facility policy titled Infection Prevention and Control Program revealed, This facility has developed and maintains an infection prevention and control program that provides a safe, sanitary, and comfortable environment to help prevent the development and transmission of infection .A review of the facility policy titled Hand Hygiene Policy… […]

• No harm, potential for more than minimal, isolatedF644May 15, 2025

  Based on interviews, record reviews, and facility policy review, the facility failed to complete a significant change assessment and submit a required Level II Preadmission Screening and Resident Review (PASRR) for one (1) of two (2) residents reviewed for PASRR (Resident #16). Specifically, the facility failed to submit a PASRR Level II and complete a significant change assessment after Resident #16 was diagnosed with major mental illness, including bipolar disorder and Major Depressive Disorder, Recurrent, Severe with Psychotic Symptoms. […]