Deficiency Records for Jefferson City Nursing and Rehabilitation Ctr, LLC
Updated as of April 01, 2024
A list of the most recent deficiencies for Jefferson City Nursing and Rehabilitation Ctr, 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? |
|---|---|---|---|---|
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-11-14 | 2023-12-27 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-09-29 | 2023-10-23 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2023-09-29 | 2023-10-23 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-06-28 | 2023-08-11 | 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 | 2023-06-28 | 2023-08-11 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-06-28 | 2023-08-11 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-03-03 | 2023-03-03 | Y |
| 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 | 2022-08-17 | 2022-10-01 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-08-17 | 2022-10-01 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-08-17 | 2022-10-01 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2022-08-17 | 2022-10-01 | N |
| Ensure staff are vaccinated for COVID-19 | Health | 2022-08-17 | 2022-10-01 | 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 | 2022-08-17 | 2022-10-01 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2022-08-17 | 2022-10-01 | Y |
| Establish staff and initial training requirements. | Fire Safety | 2022-08-17 | 2022-10-01 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2022-08-17 | 2022-10-01 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2022-08-17 | 2022-10-01 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-08-17 | 2022-10-01 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-08-17 | 2022-10-01 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-08-17 | 2022-10-01 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-08-17 | 2022-10-01 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-08-17 | 2022-10-01 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2022-08-17 | 2022-10-01 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2022-08-17 | 2022-10-01 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-08-17 | 2022-10-01 | N |
| Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk. | Fire Safety | 2022-08-17 | 2022-10-01 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2022-01-19 | 2022-02-22 | 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 | 2022-01-19 | 2022-02-22 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-01-19 | 2022-02-22 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2021-11-04 | 2021-11-04 | Y |
| Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2021-10-08 | 2021-11-04 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2021-07-09 | 2021-08-02 | Y |
| Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services. | Health | 2021-07-09 | 2021-08-02 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2021-07-09 | 2021-08-02 | Y |
| Ensure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration. | Health | 2021-07-09 | 2021-08-02 | Y |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2019-10-04 | 2019-11-15 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2019-10-04 | 2019-11-15 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2019-10-04 | 2019-11-15 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2019-10-04 | 2019-11-15 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-10-04 | 2019-11-15 | 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 | 2019-10-04 | 2019-11-15 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-10-04 | 2019-11-15 | N |
| Establish an Emergency Preparedness Program (EP). | Fire Safety | 2019-10-04 | 2019-11-15 | N |
| Meet other general requirements. | Fire Safety | 2019-10-04 | 2019-11-15 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2019-10-04 | 2019-11-15 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2019-10-04 | 2019-11-15 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-10-04 | 2019-11-15 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2019-10-04 | 2019-11-15 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-10-04 | 2019-11-15 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2019-10-04 | 2019-11-15 | N |
| Ensure that waiting areas, nurse?s stations, gift shops, and cooking facilities, open to the corridor are properly protected. | Fire Safety | 2019-10-04 | 2019-11-15 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-10-04 | 2019-11-15 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2019-10-04 | 2019-11-15 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-10-04 | 2019-11-15 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2019-10-04 | 2019-11-15 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2019-10-04 | 2019-11-15 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-10-04 | 2019-11-15 | N |
| Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk. | Fire Safety | 2019-10-04 | 2019-11-15 | 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 | 2024-02-08 | Not Fixed | N |
| Ensure each resident receives an accurate assessment. | Health | 2024-02-08 | Not Fixed | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-02-08 | Not Fixed | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2024-02-08 | Not Fixed | N |
| 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 | 2024-02-08 | Not Fixed | 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 | 2024-02-08 | Not Fixed | N |
| Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | Health | 2024-02-08 | Not Fixed | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2024-02-08 | Not Fixed | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-02-08 | Not Fixed | N |
| Provide and implement an infection prevention and control program. | Health | 2024-02-08 | Not Fixed | N |
| Establish an Emergency Preparedness Program (EP). | Fire Safety | 2024-02-08 | Not Fixed | N |
| Establish staff and initial training requirements. | Fire Safety | 2024-02-08 | Not Fixed | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2024-02-08 | Not Fixed | 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 | 2024-02-08 | Not Fixed | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2024-02-08 | Not Fixed | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2024-02-08 | Not Fixed | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-02-08 | Not Fixed | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2024-02-08 | Not Fixed | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2024-02-08 | Not Fixed | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2024-02-08 | Not Fixed | N |
| Have restrictions on the use of highly flammable decorations. | Fire Safety | 2024-02-08 | Not Fixed | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2024-02-08 | Not Fixed | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2024-02-08 | Not Fixed | N |
| Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk. | Fire Safety | 2024-02-08 | Not Fixed | N |
