A list of the most recent deficiencies for Jefferson Health Care. 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? |
|---|---|---|---|---|
| Honor the resident's right to manage his or her financial affairs. | Health | 2023-09-22 | 2023-11-06 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2023-09-22 | 2023-11-06 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2023-09-22 | 2023-11-06 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2023-09-22 | 2023-11-06 | N |
| Assure that each resident?s assessment is updated at least once every 3 months. | Health | 2023-09-22 | 2023-11-06 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2023-09-22 | 2023-11-06 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-09-22 | 2023-11-06 | N |
| Ensure a qualified health professional conducts resident assessments. | Health | 2023-09-22 | 2023-11-06 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2023-09-22 | 2023-11-06 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-09-22 | 2023-11-06 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-09-22 | 2023-11-06 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-09-22 | 2023-11-06 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-09-22 | 2023-11-06 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-09-22 | 2023-11-06 | N |
| Post nurse staffing information every day. | Health | 2023-09-22 | 2023-11-06 | N |
| Ensure that residents are free from significant medication errors. | Health | 2023-09-22 | 2023-11-06 | 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 | 2023-09-22 | 2023-11-06 | N |
| Provide or obtain dental services for each resident. | Health | 2023-09-22 | 2023-11-06 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-09-22 | 2023-11-06 | N |
| Provide or get specialized rehabilitative services as required for a resident. | Health | 2023-09-22 | 2023-11-06 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-09-22 | 2023-11-06 | Y |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2023-09-22 | 2023-11-06 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2023-09-22 | 2023-11-06 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2023-09-22 | 2023-11-06 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2023-09-22 | 2023-11-06 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2023-09-22 | 2023-11-06 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-09-22 | 2023-11-06 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2023-09-22 | 2023-11-06 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-09-22 | 2023-11-06 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-09-22 | 2023-11-06 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-09-22 | 2023-11-06 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-09-22 | 2023-11-06 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-06-06 | 2023-06-06 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-12-14 | 2023-01-13 | Y |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2022-10-18 | 2022-11-25 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2022-10-18 | 2022-11-25 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-10-18 | 2022-11-25 | N |
| Assure that each resident?s assessment is updated at least once every 3 months. | Health | 2022-10-18 | 2022-11-25 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2022-10-18 | 2022-11-25 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-10-18 | 2022-11-25 | N |
| Provide activities to meet all resident's needs. | Health | 2022-10-18 | 2022-11-25 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-10-18 | 2022-11-25 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-10-18 | 2022-11-25 | 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 | 2022-10-18 | 2022-11-25 | N |
| Ensure that nurse aides who have worked more than 4 months, are trained and competent; and nurse aides who have worked less than 4 months are enrolled in appropriate training. | Health | 2022-10-18 | 2022-11-25 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2022-10-18 | 2022-11-25 | 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 | 2022-10-18 | 2022-11-25 | N |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2022-10-18 | 2022-11-25 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-10-18 | 2022-11-25 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-10-18 | 2022-11-25 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2022-10-18 | 2022-11-25 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2022-10-18 | 2022-11-25 | N |
| Establish policies and procedures for sheltering. | Fire Safety | 2022-10-18 | 2022-11-25 | N |
| Establish staff and initial training requirements. | Fire Safety | 2022-10-18 | 2022-11-25 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2022-10-18 | 2022-11-25 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2022-10-18 | 2022-11-25 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2022-10-18 | 2022-11-25 | N |
| Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire. | Fire Safety | 2022-10-18 | 2022-11-25 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2022-10-18 | 2022-11-25 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-10-18 | 2022-11-25 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-10-18 | 2022-11-25 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2022-10-18 | 2022-11-25 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-07-13 | 2022-08-12 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2022-07-13 | 2022-08-12 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-02-02 | 2022-02-02 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-07-29 | 2021-07-29 | Y |
| Ensure each resident receives an accurate assessment. | Health | 2019-12-18 | 2020-01-10 | 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 | 2019-12-18 | 2020-01-10 | N |
| Provide or obtain dental services for each resident. | Health | 2019-12-18 | 2020-01-10 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2019-12-18 | 2020-01-10 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2019-12-18 | 2020-01-10 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2019-12-18 | 2020-01-10 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2019-12-18 | 2020-01-10 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-12-18 | 2020-01-10 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2019-12-18 | 2020-01-10 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-12-18 | 2020-01-10 | N |
