Every finding on record at Jefferson Park at White Pine

Based on facility policy review, observation, and interview, the facility failed to ensure the kitchen and kitchen equipment was maintained in a clean and sanitary condition for 1 kitchen ([NAME] House) of 3 kitchens observed which had the potential to affect 10 of 10 residents.The findings include:Review of the facility's policy titled, Cleaning & Sanitation, dated 9/2/2020, revealed .The Director of Food and Nutrition Services will develop, implement, and monitor schedules for cleaning, sanitizing, and maintenance .To ensure food services department is maintained .as well as a clean, sanitary, and safe environment .During an observation of the cooking area and interview on 5/26/2026 at 11:15 AM, with Certified Nursing Assistant (CNA) A, revealed a small food processer stored in an upper cabinet with splatters of a brown substance on the exterior of the food processer and the on/off button. CNA A confirmed the food processer was not stored in a clean and sanitary condition and needed to be cleaned. During an observation of the kitchen counter and interview on 5/26/2026 at 11:17 AM, with CNA A, revealed an electric can opener with a white crust-like debris and a thick brownish black substance present on the blade of the electronic can opener. CNA A confirmed the electric can opener blade was not stored in a clean and sanitary condition and needed to be cleaned. During an observation of a lower kitchen cabinet (left of the dishwasher) and interview on 5/26/2026 at 11:18 AM, with CNA A, revealed a dry tan crust-like debris on the top shelf of the cabinet. Further observation revealed a toaster stored on the top shelf of the cabinet with dry tan crust-like debris in the bottom of the toaster, top perimeter of the toaster, and on the shelf. CNA A confirmed the toaster and top shelf in the kitchen cabinet was not in a clean and sanitary condition and needed to be cleaned.During an observation of a ceiling Heating, Ventilation, and Cooling (HVAC) return grill (adjacent and above to the kitchen stove and food preparation counter) and a ceiling HVAC vent (directly above the food preparation counter) in the kitchen and interview on 5/26/2026 at 11:28 AM, with CNA A, revealed a grayish brown fine dry matter covering the HVAC return grill and vent. CNA A stated the maintenance staff at the facility were responsible for cleaning the HVAC vents and return grills. CNA A confirmed the HVAC return grill and vent were .dusty . and needed to be cleaned.During an observation of 4 hanging light fixtures in the kitchen area (3 hanging light fixtures above the eating counter) and (1 hanging light fixture above the 3-compartment sink) and interview on 5/26/2026 at 11:35 AM, with CNA A, revealed a grayish white fine dry matter (possibly dust) covering the outside perimeter of the hanging light fixtures. CNA A stated .those are dusty . CNA A confirmed the hanging light fixtures needed to be cleaned. During an observation of a bottom kitchen drawer (directly beneath the microwave) and interview on 5/26/2026 at 11:37 AM, with CNA A, revealed an orange, green, and tan crust-like debris around the front top perimeter of the drawer and an orange crust-like debris on the inside bottom of the drawer. CNA A confirmed the kitchen drawer was not in a clean and sanitary condition and needed to be cleaned.During an observation of a kitchen drawer (right of the microwave) and interview on 5/26/2026 at 11:39 AM, revealed a cutlery tray which contained flatware. Further observation revealed a white and tan crust-like debris around the inner perimeter of the cutlery tray. CNA A stated the cutlery tray was not in a clean and sanitary condition and needed to be cleaned. During an observation of the reach in freezer and interview on 5/26/2026 at 11:44 AM, with CNA A, revealed multiple dried brownish black debris and multiple yellow crust debris under the bottom rack of the freezer. CNA A confirmed the freezer was not in a clean and sanitary condition and needed to be cleaned. During an observation of the kitchen and interview on 5/26/2026 at 12:18 PM, the Certified Dietary Manager (CDM) confirmed the small food processer, toaster, reach in freezer, cutlery tray, hanging light fixtures, kitchen drawer directly under the microwave, and the shelf in the kitchen cabinet to the left of the dishwasher needed to be cleaned. The CDM further confirmed the condition of the kitchen was not in a clean and sanitary condition. During an observation of the HVAC return grill and vents in the kitchen and interview on 5/26/2026 at 2:40 PM, revealed the Maintenance Director (MD) stated the maintenance department was responsible for cleaning the HVAC return grills and vents as needed. The MD stated the maintenance department had no specific cleaning schedule for cleaning the HVAC grills and vents. The MD confirmed the HVAC return grill and vent in the kitchen was not in a clean and sanitary condition and needed to be cleaned.

Based on facility policy review, observation, and interview, the facility failed to ensure expired over-the-counter medications, blood collection tubes (vacuum-sealed tubes used for collecting, transporting, and processing blood samples for laboratory analysis), and supplements were discarded and not available for resident use for 1 medication room ([NAME] House) of 3 medication rooms observed for medication storage.The findings include:Review of the facility's undated and untitled policy revealed .It is the policy .to ensure all medications housed on our premises will be stored in medication room .according to the manufacturer's recommendations .all medication rooms are routinely inspected by the consultant pharmacist for discontinued, outdated, defective, or deteriorated medications with worn, illegible, or missing labels .medications are destroyed in accordance with facility policy .During an observation of the [NAME] House medication room and interview on [DATE] at 2:13 PM, with Licensed Practical Nurse (LPN) C, revealed 24 packs of UTI (Urinary Tract Infection) Stat (a supplement used to promote urinary health) with an expiration date of [DATE], 10 packs of UTI Stat with an expiration date of [DATE], 14 yellow-top 5 milliliter (ml) blood collection tubes with an expiration date of [DATE], 1 open 12 fluid ounce bottle of liquid antacid (approximately 3/4 full) with an expiration date of 2/2026, and 1 unopen 12 fluid ounce bottle of liquid antacid with an expiration date of 9/2025. LPN C confirmed the 34 packs of UTI Stat, 14 yellow-top 5 ml blood collection tubes, and both bottles of liquid antacid were expired, stored, and available for resident use. During an interview on [DATE] at 3:20 PM, the Director of Nursing (DON) confirmed the 24 packs of UTI Stat with an expiration date of [DATE], 10 packs of UTI Stat with an expiration date of [DATE], 14 yellow-top 5 ml blood collection tubes with an expiration date of [DATE], 1 open 12 fluid ounce bottle of liquid antacid with an expiration date of 2/2026, and 1 unopen 12 fluid ounce bottle of liquid antacid with an expiration date of 9/2025 should have been discarded and not available for resident use.

Based on review of the facility's Certification and Survey Provider Enhanced Reporting (CASPER) Report Fiscal Year (FY) for the first Quarter of 2026 (October 1-December 31), 2026, staffing schedule review, employee timesheet review, and interviews the facility failed to submit accurate staffing information to the Payroll Based Journal, (PBJ) for 5 of 92 days.Findings include:Review of the CASPER Report for the first quarter 2026 revealed, .No RN [Registered Nurse] Hours .Triggered .Triggered + Four or More Days Within the Quarter with no Registered Nurse Hours. See Infraction Dates .10/13 [10/13/2025] .10/14 [10/14/2025] .11/1 [11/1/2025] .11/2 [11/2/2025] .11/16 [11/16/2025] .Review of the staffing schedules and employee timesheets dated 10/13/2025-11/16/2025, revealed 8 hours of continuous RN coverage, at minimum, for the following days: 10/13/2025, 10/14/2025, 11/1/2025, 11/2/2025, and 11/16/2025. During an interview on 5/28/2026 at 11:04 AM, the Administrator confirmed the facility failed to submit accurate information to the PBJ for the RN hours worked for 10/13/2025, 10/14/2025, 11/1/2025, 11/2/2025, and 11/16/2025. During review of timesheets and interview on 5/28/2026 at 3:00 PM, with the Administrator and Human Resource Director (HRD) revealed RN's had timesheets to show hours worked on 10/13/2025, 10/14/2025 and 11/1/2025. The HRD stated the DON worked 11/2/2025 and 11/16/2025 with no time sheet due to being a salaried position. During an interview on 5/28/2026 at 3:15 PM, the DON confirmed she worked as RN coverage for 8 continuous hours on 11/2/2025 and 11/16/2025.

Based on facility policy review, medical record review, and interview, the facility failed to develop a comprehensive person-centered care plan for 3 residents (Resident #25, Resident #6, and Resident #31) of 3 residents reviewed for Activities care planning. The findings include: Review of the facility's policy titled, Care Plan Implementation and Process, dated 6/4/2025, revealed .Comprehensive Care Plan Implementation(s) must be done within 21 days of admission .then reviewed every 90 days or changes made as needed . Review of the medical record revealed Resident #25 was admitted to the facility on [DATE] with diagnoses including Parkinson's Disease, Hypertension, and Insomnia. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #25 had severe cognitive impairment. Review of the comprehensive care plan for Resident #25 date initiated 10/15/2024 and revised 4/6/2026, revealed the following in the Activities section .resident has anxiety and depression .resident has hx [history] of dysphagia [a medical condition that causes difficulty swallowing] .resident has an ADL [activities of daily living] self-care performance deficit d/t [due to]: Parkinson's disease .resident has hypertension [high blood pressure] . Further review revealed the care plan had no person-centered care plan information related to activities participation, resident preferences, or goals and interventions. Review of the medical record revealed Resident #6 was admitted to the facility on [DATE] with diagnoses including Dysphagia, Hypertension, and Hypothyroidism. Review of a quarterly MDS assessment dated [DATE], revealed Resident #6 scored a 15 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident was cognitively intact. Review of the comprehensive care plan for Resident #6 initiated 12/16/2025 and revised 4/27/2026, revealed the following in the Activities section .Resident has dysphagia and is NPO [does not consume food by mouth] .resident has hypertension .resident has dx [diagnosis] of: hyperglycemia . Further review revealed the care plan had no person-centered information related to activities participation or resident preferences, resident preferences, or goals and interventions. Review of the medical record revealed Resident #31 was admitted to the facility on [DATE] with diagnoses including Aftercare following Joint Replacement Surgery, Presence of Artificial Right Hip Joint, and Type II Diabetes. Review of an admission MDS assessment dated [DATE], revealed Resident #31 scored a 15 on the BIMS assessment which indicated the resident was cognitively intact. Review of the comprehensive care plan for Resident #31 initiated 4/10/2026 and revised 4/26/2026, revealed .Impaired communication: Difficulty making needs known and/or difficulty understanding others due to impaired hearing .the resident has Hypertension .the resident has Dx [diagnosis] of osteoarthritis to Right Hip . Further review revealed the care plan had no person-centered information related to activities participation or resident preferences, resident preferences, or goals and interventions. During an interview on 5/28/2026 at 2:55 PM, the Administrator confirmed it was her expectation the Activities section of the care plan would contain the results of the Activities assessment to include resident activity preferences. During an interview on 5/28/2026 at 3:24 PM, the Social Services Director confirmed the activities preferences were not included in the Activities section of the comprehensive care plan for Resident #25, Resident #6, and Resident #31.