Jones Harrison Residence

In the surveyor’s words

From the most serious findings on record at Jones Harrison Residence, in the surveyor’s own words.

• Immediate jeopardy, isolatedF678Jan 19, 2022

  Based on interview and document review, the facility failed to initiate cardiopulmonary resuscitation (CPR) in accordance with physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . This resulted in an immediate jeopardy (IJ) situation when CPR was not initiated when R7 was found without a pulse and respirations. The deficiency was identified as past noncompliance and issued at Immediate Jeopardy (IJ). The IJ began on [DATE], when the facility failed to provide CPR for R7 after R7 was found unresponsive and later died . The administrator and director of nursing (DON) were notified of the IJ at past noncompliance on [DATE] at 5:50 p.m Corrective action was taken prior to the survey. The facility corrected the deficient practice on [DATE]. […]

• Actual harm, isolatedF689Jul 2, 2026

  Based on observation and interview, the facility failed to ensure interventions to reduce the risk of falls were implemented for 1 of 3 residents (R1) reviewed for accidents. R1 fell from her bed when the nursing assistant (NA)-A repositioned her alone, R1's care planned interventions required two staff for repositioning. R1's fall resulted in a femur fracture with surgical intervention.Findings include: R1's care plan dated 12/15/26 indicated R1 required substantial assistance from two staff to assist and reposition every 2 hours. Substantial/maximum assistance of two staff for dressing assistance, bathing, and toilet use. R1 was able to determine when she has voided or had a bowel movement and would call for staff assistance when her incontinent brief required changing. […]

• No harm, potential for more than minimal, widespreadF812Nov 14, 2024

  Based on observation, interview and record review, the facility failed to test the levels of chemicals used on the three compartments sink to sanitize the pots used for meal preparation; failed to ensure dry goods removed from original packaging were stored in a manner to reduce the risk for cross contamination; and failed to properly monitor food temperatures before serving food to residents. These findings had the potential to affect all 102 residents, staff, and visitors, who consumed food prepared from the main production kitchen. Findings include: During observation and interview on 11/12/24 at 8:20 a.m., an initial kitchen tour was completed with culinary coordinator (CC) and the following items were identified: 1. […]

• No harm, potential for more than minimal, widespreadF812Sep 1, 2022

  During observation, interview, and document review the facility failed to ensure monitoring and timely removal of food stored in the facility's refrigerators. This had the potential to affect all 104 residents who received food prepared in the kitchen. In addition, the facility failed to ensure the resident refrigerator and freezer available on third floor for resident and family use was maintained in a clean and sanitary manner. This had the potential to affect any residents who used the unit refrigerator to store their food. Further, the facility failed to have a system in place to monitor refrigerator and freezer temperatures in the kitchenettes. This had the potential to affect all residents who were served food from the kitchenettes. […]

• No harm, potential for more than minimal, patternF804Sep 1, 2022

  Based on observation, interview, and document review, the facility failed to ensure food was served at a palatable and appetizing temperature for 7 of 7 residents (R35, R97, R198, R199, R27, R69,R51) reviewed for food. Findings include: R35's quarterly Minimum Data Set (MDS) dated [DATE], identified R35 was severely cognitively impaired. R97's annual MDS dated [DATE], identified R97 was severely cognitively impaired. R198's quarterly MDS dated [DATE], identified 198 was severely cognitively impaired. R199's entry MDS dated [DATE], was not complete and did not identify cognitive status. R199's Face Sheet dated 9/1/22, indicated a diagnosis of dementia. During observation n 9/01/22, at 7:26 a.m. food service for breakfast was plated in the kitchen. […]