Jefferson Healthcare Center

In the surveyor’s words

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

• No harm, potential for more than minimal, widespreadF725Jul 22, 2022

  Based on observation, interview, and record review the facility failed to provide sufficient staff to meet the needs the residents. This affected Resident's #43, #69 and #78 and had the potential to affect all 87 residents residing in the facility. Findings include: Interview on 07/18/22 at 1:50 P.M. with Resident #78 stated there was not enough staff because there was only one State tested Nursing Assistant (STNA) for every resident on the hallway and could take up to 30 minutes for staff to respond to the call light. Interview on 07/18/22 at 2:44 P.M. with Resident #43 revealed there was not enough staff since there was only one STNA all the time available on the hallway. Interview on 07/20/22 at 12:26 P.M. […]

• No harm, potential for more than minimal, widespreadF838Jul 22, 2022

  Based on record review and interview, the facility failed to ensure staff needs were identified on the facility assessment as required. This had the potential to affect all 87 residents. Findings include: Review of the facility assessment, dated 07/07/22 to 07/28/22, revealed it did not contain an evaluation of the overall number of facility staff needed to ensure a sufficient number of qualified staff were available to meet the needs of each resident. Interview on 07/22/22 at 9:39 A.M. with Director of Nursing, Administrator, and Corporate Nurse #296 verified the facility assessment did not contain facility staffing needs as required.

• No harm, potential for more than minimal, patternF584Jul 22, 2022

  Based on observation and interview, the facility failed to ensure a homelike environment free of gouges and unpainted patched areas on the walls in resident rooms and common hallways. This affected 13 Residents (#10, #16, #26, #35, #37, #49, #54, #56, #60, #84, #87, #289, #290). The facility census was 87. Findings include: Observation during an environmental tour on 07/22/22 from 8:40 A.M. to 8:51 A.M. with Maintenance Director #207 revealed the following findings: · Resident #10 and #16's room had one large gouge on the bottom portion of the wall by the window with paint peeling away from the area. […]

• No harm, potential for more than minimal, patternF880Jul 22, 2022

  Based on observation, interview, and the review of guidelines from the Centers for Disease Control and Prevention (CDC), the facility failed to maintain infection control practices for the spread of infectious diseases by not ensuring staff properly donned and maintained the wearing of facemasks while in resident care areas and hand hygiene was not performed after removing gloves. This affected two (Residents #295 and #413) and had the potential to affect all 87 residents residing in the facility. Findings include: 1. Observation on 07/18/22 at 10:04 A.M. […]

• No harm, potential for more than minimal, isolatedF609Aug 6, 2026

  Based on record review, interview, review of hospital paperwork, and facility policy review, the facility failed to report an allegation of abuse from Resident #59's family to the appropriate parties. This affected one (Resident #59) of three residents reviewed for change in condition. The facility census was 87.Findings include:Review of the medical record for Resident #59 revealed an admission date of 11/01/25. Diagnoses included periprosthetic fracture around internal prosthetic left joint, fracture of the lower end of the left femur, dysphagia, dementia, and Alzheimer's disease.Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #59 had cognitive impairment with a memory problem. […]