A list of the most recent deficiencies for The Jefferson. 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? |
|---|---|---|---|---|
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-01-12 | 2023-02-23 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2023-01-12 | 2023-02-23 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-01-12 | 2023-02-23 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-01-12 | 2023-02-23 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-01-12 | 2023-02-23 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2023-01-12 | 2023-02-23 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2023-01-12 | 2023-02-23 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-01-12 | 2023-02-23 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2023-01-12 | 2023-02-23 | N |
| Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse. | Health | 2023-01-12 | 2023-02-23 | N |
| Provide a neutral and fair arbitration process and agree to arbitrator and venue. | Health | 2023-01-12 | 2023-02-23 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2023-01-12 | 2023-02-23 | N |
| Report COVID19 data to residents and families. | Health | 2023-01-12 | 2023-02-23 | N |
| Perform COVID19 testing on residents and staff. | Health | 2023-01-12 | 2023-02-23 | N |
| Post nurse staffing information every day. | Health | 2023-01-12 | 2023-02-23 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-01-12 | 2023-02-23 | Y |
| 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 | 2021-08-20 | 2021-09-21 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2021-08-20 | 2021-09-21 | N |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2021-08-12 | 2021-09-14 | N |
| Post nurse staffing information every day. | Health | 2021-08-12 | 2021-09-14 | 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 | 2021-08-12 | 2021-09-14 | N |
| Dispose of garbage and refuse properly. | Health | 2021-08-12 | 2021-09-14 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-08-12 | 2021-09-14 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-03-06 | 2019-04-18 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-03-06 | 2019-04-18 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-03-06 | 2019-04-18 | N |
