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.

• Actual harm, isolatedF656Nov 16, 2022

  Based on medical record review, review of facility investigation and interview the facility failed to ensure 1 resident (Resident #1) of 3 sampled residents was transferred according to the comprehensive care plan which resulted in a fracture to Resident #1's right femur and harm for Resident #1. The findings included: Medical record review revealed Resident #1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Medical record review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 7 which indicated the resident was severely cognitively impaired. The resident was totally dependent for transfers with 2-person assist. […]

• Actual harm, isolatedF689Nov 16, 2022

  Based on review of facility policy, medical record review, review of facility investigation and interview the facility failed to ensure 1 resident (Resident #1) of 3 sampled residents was transferred with the use of a mechanical lift which resulted in a fracture to Resident #1's right femur and harm for Resident #1. The findings included: Review of a facility policy Resident Lifting Policy effective 9/18/1997 showed .[facility] will be considered a 'LIFT FREE FACILITY' .mechanical lifts will be provided to do all types of lifting and transferring of residents . Medical record review revealed Resident #1 was admitted to the facility on [DATE] with diagnoses including Dementia, Mood Disorder, Foot Drop Right and Left Feet and [CONDITION(S)]. […]

• No harm, potential for more than minimal, widespreadF812Aug 17, 2022

  Based on facility policy review, observation, and interview the facility failed to maintain a sanitary kitchen with open to air food items/unsealed food items in 1 of 2 bread racks. The facility failed to maintain kitchen equipment in a sanitary manner in 1 of 1 kitchen. The facility failed to maintain a sanitary kitchen with open to air/unsealed food items, not placed in a container after opened, in 1 of 2 food preparation tables. The facility failed to maintain a sanitary kitchen with open to air/unsecured, undated with an open date, and undated food items with a use by date in 1 of 1 walk in freezers. […]

• No harm, potential for more than minimal, isolatedF644Dec 12, 2025

  Based on facility policy review, medical record review and interview, the facility failed to resubmit a Pre-admission Screening and Resident Review (PASARR) timely after a new mental health diagnosis was added for 4 residents (Residents #3, #40, #43, and #143) of 8 residents reviewed for PASRR (PASARR). The findings include: Review of the facility's undated policy titled, PASRR POLICY, revealed .ensure that individuals with a mental disorder .receives care and services in the most integrated setting .All applicants to this facility will be screened for serious mental disorders .Any level II [2] resident who experiences a significant change in status will be screened via [by] submitting a new level I [1] PASRR . […]

• No harm, potential for more than minimal, isolatedF657Dec 12, 2025

  Based on review of facility policy, review of medical records, and interview, the facility failed to revise the comprehensive care plan for 1 resident (Resident #117) of 29 residents reviewed for care plans. The findings include:Review of the facility's policy titled, CARE PLAN IMPLEMENTATION AND PROCESS, revised 6/4/2025, revealed .Comprehensive Care Plan .reviewed every 90 days or changes .be made as needed . Review of the medical record revealed Resident #117 was admitted to the facility on [DATE] with diagnoses including History of Falling, Cerebral Infarction, and Muscle Weakness. […]