Jefferson Nursing and Rehabilitation Center

In the surveyor’s words

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

• Immediate jeopardy, patternF600May 17, 2025

  Based on observation, interview and record review, the facility failed to ensure residents had the right to be free from abuse and neglect for 9 of 22 residents (Resident #2, Resident #3, Resident #4, Resident #9, Resident #13, Resident #19, Resident #20, Resident #25, and Resident #26) reviewed for abuse. 1. The facility failed to ensure Resident #3 was free from physical abuse when Resident #2 and Resident #3 had a physical altercation on 10/23/2024. 2. The facility failed to ensure Resident #3 was free from physical abuse when Resident #4 and Resident #3 was in a physical altercation and Resident #4sustained injuries on 11/09/2024. 3. […]

• Immediate jeopardy, patternF689May 17, 2025

  Based on observation, interview and record review, the facility failed to ensure residents received adequate supervision to prevent accidents for 9 of 22 residents (Resident #2, Resident #3, Resident #4, Resident #9, Resident #13, Resident #19, Resident #20, Resident #25, and Resident #26) reviewed for supervision to prevent accidents. 1. The facility failed to ensure Resident #3 was free from physical abuse when Resident #2 and Resident #3 had a physical altercation on 10/23/2024. 2. The facility failed to ensure Resident #3 was free from physical abuse when Resident #4 and Resident #3 was in a physical altercation and Resident #4sustained injuries on 11/09/2024. 3. […]

• Immediate jeopardy, isolatedF607May 17, 2025

  Based on observation, interview and record review, the facility failed to implement the written abuse policy to ensure an allegation of physical abuse was reported immediately to the Abuse Coordinator, State Agency, and implement measures to ensure residents were protected from further abuse after an allegation of abuse for 1 of 22 residents (Resident #1) reviewed for allegations of abuse. 1. The facility failed to ensure CNA B was suspended/ terminated or removed from all residents after a physical abuse allegation was reported on 03/11/2025. 2. The facility failed to immediately report the physical abuse allegation to the Abuse Coordinator for Resident #1. The non-compliance was identified as past non-compliance. The Immediate Jeopardy began on 03/11/2025 and ended on 03/17/2025. […]

• Actual harm, isolatedF580Apr 27, 2021

  Based on observation, interview and record review, the facility failed to ensure the physician and responsible party was consulted for a change of condition for 2 of 5 residents reviewed for notification of changes. (Resident #18 and #3) The facility failed to consult the physician when Resident #18 had a deterioration in his sacral wound, penile erosion from an indwelling catheter, and worsening of MASD on his buttocks. The facility failed to consult physician or notify the responsible party for a change in condition when Resident #3 developed open wounds on her abdomen and back of her thigh. This failure could place residents at risk for unnecessary pain, delay in treatment, and decreased quality of life. Findings included: 1. […]

• Actual harm, isolatedF686Apr 27, 2021

  Based on observation, interview and record review, the facility failed to provide the necessary treatment and services, based on the comprehensive assessment and consistent with professional standards of practice to promote healing and prevent worsening of pressure injuries to 2 of 5 residents (Resident #18 and #5 ) reviewed for pressure ulcers. The facility failed to assess and provide care for Resident #18's facility acquired pressure injuries. Resident had a Stage 3 pressure injury to the sacrum and a Stage 3 pressure injury to the head of the penis (rounded head of the penis). The facility failed to assess and provide care for Resident #5's facility acquired pressure injuries. […]