Jefferson Health Care

In the surveyor’s words

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

• Immediate jeopardy, isolatedF689Sep 18, 2025

  Based on observation, interview and record review, the facility failed to ensure a resident's environment was free from accident hazards, when one resident (Resident #1) was not secured appropriately with a lap belt in the facility van during transport on 9/8/25 and the resident was ejected from his/her wheelchair. The resident's face hit the console/cup holder in front of him/her, resulting in his/her lip bleeding and swelling and facial bruising. The resident was admitted to the hospital for observation. Facility staff did not call 911 or notify any facility staff at that time. The facility census was 64 residents. The Administrator was notified on 9/18/25 of the past noncompliance immediate jeopardy which began on 9/9/25. […]

• No harm, potential for more than minimal, widespreadF838Apr 4, 2025

  Based on interview and record review, the facility failed to assess the resident's level of acuity including how many residents were dependent on transfers, bathing, feeding assistance, and level of care needs for the resident population to determine staffing needs. The facility census was 64 residents. 1. Review of the facility's Facility Assessment, revised date 8/2/24, showed: -The facility did not have documentation showing the base staffing levels were meeting the resident's acuity or care needs. […]

• No harm, potential for more than minimal, widespreadF865Apr 4, 2025

  Based on interview and record review the facility failed to ensure a Quality Assurance Performance Improvement (QAPI) plan was developed to drive Quality Assurance (QA) measures that addressed the staffing needs for the residents based on the Payroll Base Journals (PBJ) reports that triggered a low staffing alert for the second and fourth quarters in the year 2024. This failure had the potential to affect all residents who currently lived in the facility. The facility census was 64 residents. […]

• No harm, potential for more than minimal, widespreadF880Apr 4, 2025

  Based on observation, interview and record review, the facility failed to maintain an infection prevention and control program to help prevent the development and transmission of communicable diseases when the facility failed to provide Tuberculosis (TB-a communicable disease that affected the lungs, that was characterized by fever, cough, difficulty in breathing, abnormal lung tissue and function) testing for three sampled residents (Residents #63, #57, and #33) out of five residents sampled for TB screening; failed to ensure nursing staff ensured clean techniques were followed when administering the residents medication by not cleaning a surface or laying down a barrier when placing medications on a resident's bedside tray table before administering them via feeding tube for one… […]

• No harm, potential for more than minimal, widespreadF761Sep 22, 2023

  Based on observation, interview, and record review, the facility failed to ensure two nurses were counting narcotics at the beginning and end of their shifts; to ensure staff kept the medication carts locked when staff was not in attendance of it; to ensure the medication refrigerator was within the correct temperature range; to ensure there was a means to lock the medication safe if the electricity went off; to dispose of expired medications, and to date medications that had been opened. […]