The Jefferson

In the surveyor’s words

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

• Immediate jeopardy, isolatedF600Mar 12, 2026

  Based on staff interview, facility document review, and clinical record review, the facility staff failed to protect the resident from physical abuse while obtaining a urine sample that resulted in hospitalization, thus resulting in the determination of Immediate Jeopardy (IJ) for one of 36 residents in the survey sample, Resident #42. After IJ was removed, the scope and severity was lowered to a level 3 (three), isolated, harm. The findings include: For Resident #42 (R42), the facility staff failed to protect the resident from physical abuse while obtaining a urine sample which resulted in IJ and harm. R42 was admitted to the facility with diagnosis that included but was not limited to benign prostatic hyperplasia (1). […]

• Immediate jeopardy, isolatedF604Mar 12, 2026

  Based on staff interview, facility document review, and clinical record review, the facility staff failed to keep the resident from being physically restrained while obtaining a urine sample that resulted in hospitalization, thus resulting in the determination of Immediate Jeopardy (IJ) for one of 36 residents in the survey sample, Resident #42, (R42). After IJ was removed, the scope and severity was lowered to a level 3 (three), isolated, harm. The findings include: For Resident #42 (R42), the facility staff failed to protect the resident from being physically restrained while obtaining a urine sample which resulted in IJ and harm. R42 was admitted to the facility with diagnosis that included but was not limited to benign prostatic hyperplasia (1). […]

• Immediate jeopardy, isolatedF806Mar 12, 2026

  Based on clinical record review and staff interview, the facility staff failed to prevent an allergic reaction to a documented food allergy which resulted in the resident requiring emergency medical treatment, thus resulting in a determination of Jeopardy (IJ) for one of 36 residents in the survey sample, Resident #43. After IJ was removed, the scope and severity was lowered to a level 3 (three), isolated, harm. The findings include: For Resident 43 (R43), facility staff served the resident lobster ravioli when he had a documented shellfish allergy which resulted in IJ and harm. R43 was admitted to the facility with diagnoses that included but were not limited to cognitive communication deficit (1). […]

• Actual harm, isolatedF552Mar 12, 2026

  Based on staff interview, clinical record review, facility document review, the facility staff failed to uphold a resident's right to refuse care and treatment causing harm and resulting in a hospitalization for one of 36 residents in the survey sample, Resident #42. The findings include:For Resident #42 (R42), the facility staff forced the procedure to obtain a urine sample by physically restraining and forcing the insertion of a catheter causing harm resulting in hospitalization. R42 was admitted to the facility with diagnosis that included but was not limited to benign prostatic hyperplasia (1). […]

• No harm, potential for more than minimal, widespreadF678Mar 12, 2026

  Based on observation, staff interview, and facility document review, the facility staff failed to maintain emergency medical equipment in a sanitary manner and ensure the supplies on the emergency medical cart were not expired, for one of one unit.Observation was made on [DATE] at 12:13 p.m. of the emergency medical cart (crash cart) on the health care unit. The following observations were made:Oxygen tank was 2% full, nearly empty.Top of the cart:Suction machine was not covered, only a mesh covering so air and dust can get through. There was no oxygen mask, no nasal cannula or normal saline, per their list of required items. […]