Jefferson House

In the surveyor’s words

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

• No harm, potential for more than minimal, widespreadF851Jan 28, 2025

  Based on staff interview and review of Payroll Based Journal (PBJ) submissions for Quarter 1 (October 1, 2024 through December 31, 2024) and Quarter 2 (January 1, 2024 through March 31, 2024) the facility failed to ensure the PBJ data was submitted on time. The findings include: PBJ submissions for Quarter 1 of 2024 and Quarter 2 of 2024 identified the facility as a 1-star rating and excessively low weekend staffing metric was suppressed for the facility for Quarter 1 and Quarter 2 of 2024. On 1/28/25 at 2:21 PM an interview with Administrator identified that the staff member who was responsible for submitting the PBJ reports had left and then came back per diem, she did not submit the PBJ on time for Quarter 1 and therefore Quarter 2 was also triggered. […]

• No harm, potential for more than minimal, widespreadF812Jul 6, 2021

  Based on observations, facility documentation review, facility policy review, and interviews for kitchen review, the facility failed to ensure the walk-in refrigerator was maintained at the appropriate temperature, and the facility failed to ensure high refrigerator temperatures were rechecked for accuracy and recorded any repeat temperature checks. The findings include: Observations and interview on 7/6/2021 at 8:48 AM with the Administrator and Food Services Manager (FSM) identified that the refrigerator temperature should be below 41 degrees Fahrenheit (F). The walk-in refrigerator temperature near the door was 46, and near the back of the walk-in refrigerator was 39 F. The Administrator identified the refrigerator door did not shut properly and they were waiting to have it repaired. […]

• No harm, potential for more than minimal, patternF585Sep 1, 2026

  Based on interviews, observations, and review of facility policy during the Resident Council meeting, the facility failed to ensure that Grievance forms policy was in accessible to residents and failed to ensure residents had knowledge of the grievance process. The findings include:Resident #9's diagnoses included arthritis, weakness, anxiety, and high blood pressure. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #9 had a Brief Interview of Mental Status (BIMS) score of 14 indicating intact cognition.Resident #15's diagnoses included difficulty in walking, weakness, depression, anxiety, and depression. The significant change MDS assessment dated [DATE] identified Resident #15 had a BIMS score of 4 indicating severe cognitive impairment. […]

• No harm, potential for more than minimal, patternF684Jan 28, 2025

  Based on observations, review of the clinical record, facility documentation, facility policy and interviews for 1 of 3 residents (Resident #29) reviewed for pressure ulcers, the facility failed to properly document a change in skin condition and notify the provider and for 1 of 4 sampled residents, (Resident #57) reviewed for accidents, the facility failed to implement a physician's order for the application of padded side rails. Additionally, for 1 of 1 sampled resident (Resident #63) reviewed for choices, the facility failed to schedule an appointment with a specialist per provider recommendations and resident request, and for 1 of 3 residents (Resident #87) reviewed for general concerns, the facility failed to schedule a hematology consult per physician's order. […]

• No harm, potential for more than minimal, patternF812Jan 28, 2025

  Based on the tour of the Dietary Department, interviews, review of facility policy and facility documentation, the facility failed to ensure that beard restraints were worn appropriately, perform hand hygiene when appropriate, ensure open food items were properly closed/dated and not near debris on the floor and failed to discard expired food items. The findings include: During observations of meal service on [DATE] at 11:45 AM with the Director of Food Services, the following was identified: 1a. Dietary Aide #1 (DA) was observed at the tray line placing plated food on residents' trays wearing a beard restraint that covered only the lower half of his facial hair with the sides of his beard exposed. […]