Inspection Reports for Jefferson City Manor

The complaint investigation found that staff failed to replace the resident's wanderguard as ordered, leading to the resident leaving the facility without staff knowledge. The resident was found by a community member and returned with an abrasion. Staff documented multiple days without wanderguard placement and no replacement attempts were documented. Interviews with staff and administration confirmed lack of notification and replacement efforts prior to the incident.

Facility staff failed to replace the resident's wanderguard after identifying it was missing, resulting in the resident leaving the facility unnoticed. The facility took corrective actions including increasing wanderguard checks, staff in-service, and updating the resident's care plan.

Complaint #2649088 regarding failure to document and administer wound treatments as ordered by the physician for two residents. The complaint was substantiated based on observations, interviews, and record reviews.

Facility staff failed to document wound treatments as directed by the physician for two residents out of three sampled. Documentation on the Treatment Administration Record (TAR) was missing for multiple dates, and interviews revealed inconsistent treatment administration and documentation practices.

The facility failed to follow treatment orders for multiple residents, including failure to administer prescribed creams, notify physicians or pharmacies about unavailable medications, ensure oxygen was in place and at the correct flow rate, document daily weights, and perform ordered urinalysis tests. Several policy and procedural deficiencies were also noted.

The facility was found deficient in multiple areas including failure to thoroughly investigate and document bruises of unknown origin, incomplete significant change assessments, inadequate comprehensive care plans, failure to hold care plan meetings with residents and representatives, failure to meet professional nursing standards including medication administration and oxygen use, failure to maintain proper food temperatures, insufficient nursing staff to timely respond to call lights, and inadequate nurse aide training and education.

The complaint investigation found that staff initiated CPR on a resident with a DNR order due to failure to verify code status promptly. The Director of Nursing, administrator, and Licensed Practical Nurse interviewed were unaware or uncertain why staff did not follow the resident's wishes. The LPN stated he/she erred on the side of caution and was unaware of the code status documentation procedures.

The facility staff failed to obtain a timely advanced directive for a resident who elected DNR and inconsistently documented the resident's code status, resulting in staff initiating CPR before discovering the resident's DNR status. Interviews revealed staff were unaware or did not follow proper procedures for identifying code status.

The facility staff failed to provide adequate hygiene care, including nail care and facial hair assistance, for four out of five sampled residents. Observations and record reviews showed long nails with debris and unkempt facial hair, and shower sheets lacked documentation of provided care. Interviews with staff and residents confirmed these deficiencies, highlighting potential infection control and dignity concerns.

The facility failed to develop and implement a comprehensive person-centered care plan for one resident and failed to update care plans at least quarterly for two other residents, despite policies requiring timely updates. Interviews with the MDS Coordinator, administrator, and Director of Nursing confirmed responsibility for care plan updates and ongoing efforts to resolve these issues.

The complaint investigation involved allegations of failure to protect resident privacy, failure to report suspected abuse or theft (missing money and wallet), failure to provide ordered wound care, and unsafe medication storage and administration practices. The facility census was 71. The investigation included interviews with residents, staff including Licensed Practical Nurses, Certified Medication Technician, Director of Nursing, Social Services Designee, Maintenance Director, Therapy Director, Housekeeper, and the Administrator. The investigation found multiple deficiencies as described.

The facility failed to protect residents' privacy by leaving medical information visible in public areas, failed to report allegations of misappropriation of money in a timely manner, failed to document wound treatment administration as ordered, and failed to ensure medications were securely stored and monitored.

The facility failed to provide RN coverage for eight consecutive hours daily, maintain proper medication labeling and storage, ensure food safety and kitchen sanitation, and document coordinated hospice care plans for residents receiving hospice services.

The complaint investigation found that the resident did not receive the ordered medications Metolazone and Torsemide on 11/3/23 and 11/4/23, leading to respiratory failure and hospitalization. Staff interviews revealed confusion and lack of clarity about responsibilities for medication order entry, delivery reconciliation, and notification procedures. The resident's family raised concerns about the missing medications. The physician confirmed the importance of timely medication administration and expected notification if medications were unavailable.

The facility failed to ensure the resident was free from significant medication errors by not administering Metolazone and Torsemide as ordered and failing to notify the physician about the medication unavailability. This led to the resident's hospitalization with acute chronic hypoxic respiratory failure, pulmonary edema, and chronic kidney disease Stage IV. The facility lacked a policy for handling situations when medications could not be started as ordered.

The facility was found deficient in multiple areas including failure to maintain resident dignity, incomplete baseline care plans, inadequate assistance with activities of daily living, improper pressure ulcer care, lack of range of motion interventions, insufficient fall prevention measures, improper catheter care, incomplete respiratory care orders and plans, inappropriate use and monitoring of antipsychotic medications, food safety violations including ice machine drainage and ceiling cleanliness, infection control breaches including hand hygiene and wound care, and failure to conduct regular bed rail entrapment assessments.