Deficiency Records for Jena Nursing and Rehabilitation Center, LLC
Updated as of March 01, 2024
A list of the most recent deficiencies for Jena Nursing and Rehabilitation Center, LLC. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-08-31 | 2023-10-05 | Y |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2023-04-19 | 2023-06-19 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-04-19 | 2023-06-19 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-04-19 | 2023-06-19 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2023-04-19 | 2023-06-19 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2023-04-19 | 2023-06-19 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-04-19 | 2023-05-29 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2023-04-19 | 2023-05-29 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-04-19 | 2023-05-29 | N |
| Provide activities to meet all resident's needs. | Health | 2023-04-19 | 2023-05-29 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-04-19 | 2023-05-29 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-04-19 | 2023-05-29 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2023-04-19 | 2023-05-29 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2023-02-22 | 2023-03-29 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-02-22 | 2023-03-29 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-02-22 | 2023-03-29 | Y |
| Keep all essential equipment working safely. | Health | 2023-02-22 | 2023-03-29 | Y |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-03-21 | 2022-04-28 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2022-03-21 | 2022-04-28 | N |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2022-03-28 | 2022-04-25 | Y |
| Allow resident to participate in the development and implementation of his or her person-centered plan of care. | Health | 2022-03-28 | 2022-04-25 | Y |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2022-03-28 | 2022-04-25 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-03-28 | 2022-04-25 | N |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2022-03-28 | 2022-04-25 | N |
| Ensure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health needs of residents. | Health | 2022-03-28 | 2022-04-25 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2022-03-28 | 2022-04-25 | N |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2022-03-28 | 2022-04-25 | N |
| Ensure meals and snacks are served at times in accordance with resident?s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. | Health | 2022-03-28 | 2022-04-25 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-03-28 | 2022-04-25 | N |
| Dispose of garbage and refuse properly. | Health | 2022-03-28 | 2022-04-25 | N |
| Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. | Health | 2022-03-28 | 2022-04-25 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2022-03-28 | 2022-04-25 | Y |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2022-03-28 | 2022-04-25 | Y |
| Provide activities to meet all resident's needs. | Health | 2022-03-28 | 2022-04-25 | Y |
| Ensure the activities program is directed by a qualified professional. | Health | 2022-03-28 | 2022-04-25 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-03-28 | 2022-04-25 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-03-28 | 2022-04-25 | Y |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2022-03-28 | 2022-04-25 | Y |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2022-03-28 | 2022-04-25 | N |
| Include a process for Emergency Preparedness collaboration. | Fire Safety | 2022-03-28 | 2022-04-25 | N |
| Establish procedures for tracking staff and patients during an emergency. | Fire Safety | 2022-03-28 | 2022-04-25 | N |
| Establish policies and procedures for sheltering. | Fire Safety | 2022-03-28 | 2022-04-25 | N |
| Establish policies and procedures for medical documentation. | Fire Safety | 2022-03-28 | 2022-04-25 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2022-03-28 | 2022-04-25 | N |
| Develop a communication plan. | Fire Safety | 2022-03-28 | 2022-04-25 | N |
| Provide emergency officials' contact information. | Fire Safety | 2022-03-28 | 2022-04-25 | N |
| Provide primary/alternate means for communication. | Fire Safety | 2022-03-28 | 2022-04-25 | N |
| Establish methods for sharing information. | Fire Safety | 2022-03-28 | 2022-04-25 | N |
| Provide a means of sharing information on occupancy/needs. | Fire Safety | 2022-03-28 | 2022-04-25 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2022-03-28 | 2022-04-25 | N |
| Establish emergency prep training and testing. | Fire Safety | 2022-03-28 | 2022-04-25 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-01-21 | 2022-02-28 | Y |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2022-01-21 | 2022-02-28 | Y |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2022-01-21 | 2022-02-28 | Y |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2021-08-13 | 2021-09-17 | Y |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2021-05-13 | 2021-06-25 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2021-05-13 | 2021-06-25 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2021-05-13 | 2021-06-25 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-03-19 | 2021-04-12 | Y |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2021-03-19 | 2021-04-12 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2020-10-30 | 2021-01-14 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2020-10-30 | 2021-01-14 | N |
| Honor the resident's right to manage his or her financial affairs. | Health | 2020-10-30 | 2021-01-14 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2020-10-30 | 2021-01-14 | N |
| Ensure each resident receives an accurate assessment. | Health | 2020-10-30 | 2021-01-14 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2020-10-30 | 2021-01-14 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2020-10-30 | 2021-01-14 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2020-10-30 | 2021-01-14 | N |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2020-10-30 | 2021-01-14 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2020-10-30 | 2021-01-14 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2020-10-30 | 2021-01-14 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2020-10-30 | 2021-01-14 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2020-10-30 | 2021-01-14 | N |
| Dispose of garbage and refuse properly. | Health | 2020-10-30 | 2021-01-14 | N |
| Provide and implement an infection prevention and control program. | Health | 2020-10-30 | 2021-01-14 | N |
| Report COVID19 data to residents and families. | Health | 2020-10-30 | 2021-01-14 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2024-01-18 | Not Fixed | Y |
| Respond appropriately to all alleged violations. | Health | 2024-01-18 | Not Fixed | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-01-18 | Not Fixed | Y |
