Jefferson Manor Nursing and Rehab Ctr, LLC

In the surveyor’s words

From the most serious findings on record at Jefferson Manor Nursing and Rehab Ctr, LLC, in the surveyor’s own words.

• Immediate jeopardy, patternF600Mar 10, 2025

  Based on record review, video observation, and interviews the facility failed to ensure the residents' right to be free from neglect for all residents who resided on Hall A (Rooms ,d+[DATE]). Nursing staff neglected to respond to call lights and provide any care and services to all resident's residing on Hall A from 11:00 p.m. to 2:30 a.m. on the night of [DATE]. As a result of the identified noncompliance, serious harm, serious impairment, death, or psychosocial harm was likely to occur to the residents residing on Hall A. This deficient practice resulted in an Immediate Jeopardy (IJ) situation on [DATE] at approximately 11:00 p.m. when Resident #1, who had a physician's order for staff to visually check the resident every 2 hours, activated her call light for staff assistance. […]

• Immediate jeopardy, isolatedF689Dec 26, 2024

  Based on record review, video observation, and interviews the facility failed to ensure residents received adequate supervision to prevent elopement from the facility for 1 (#1) of 5 (#1, #2, #3, R1 and R2) sampled residents reviewed for elopement. This deficient practice resulted in an Immediate Jeopardy (IJ) situation on 12/14/2024 at 4:32 a.m. when Resident #1, a moderately cognitively impaired resident with a physician's order for staff to visually check the resident every 2 hours, eloped from the facility. On 12/14/2024, staff last visualized Resident #1 at approximately 4:00 a.m. Resident #1 was observed on video footage eloping from the facility by climbing over the patio fence at 4:32 a.m., without staff knowledge. […]

• Immediate jeopardy, isolatedF580Jun 27, 2024

  Based on interviews and record reviews, the facility failed to ensure a resident's significant change in status was reported to the physician for 1 (#1) of 3 (#1, #2 and #3) sampled residents reviewed for notification of change. This deficient practice resulted in an Immediate Jeopardy situation on [DATE] at approximately 1:12 p.m. for Resident #1, a resident requiring mechanical lift with 2 person assistance for transfers, when S8CNA transferred the resident without another staff member's assistance. The transfer resulted in Resident #1 falling from the lift to the floor. On [DATE] from 1:48 p.m. to 1:53p.m., Resident #1 told S5CNA, S6CNA and S7CNA, I am going to die and showed symptoms of increased anxiety. None of the CNAs reported this to the nurse. […]

• Immediate jeopardy, isolatedF689Jun 27, 2024

  Based on record reviews and interviews, the facility failed to ensure residents, who required two person assistance with mechanical lift transfers, remained free of accident hazards for 1 (#1) of 8 (#1, #2, #3, R1, R2, R3, R4, and R5) residents reviewed for transfers. This deficient practice resulted in an Immediate Jeopardy situation on [DATE] at approximately 1:12 p.m. for Resident #1, a resident requiring mechanical lift with 2 person assistance for transfers, when S8CNA transferred the resident without another staff member's assistance. The transfer resulted in Resident #1 falling from the lift to the floor. Resident #1 was found unresponsive at 1:45 p.m., CPR initiated, and transferred to the hospital via emergency transportation. Resident #1 expired in the hospital at 2:24 p.m. […]

• Actual harm, isolatedF689Oct 19, 2022

  Based on interviews and record reviews, the facility failed to ensure a resident received adequate supervision to prevent accidents with injury for 1 (#5) of 3 (#2, #3, and #5) residents reviewed for accidents. This deficient practice resulted in actual harm for Resident #5 when the resident was left unattended by staff on 10/14/2022. On 11/23/2021, Resident #5's physician ordered 1:1 staff supervision due to increased number of falls. On 10/14/2022, an injury of unknown origin was discovered for the resident. Resident #5 was sent to the ER, which resulted in four skin tears and a laceration to the back of the head that required 5 staples, and [MEDICATION(S)] for pain. […]