Jefferson Family Care Home #4

The facility failed to ensure that an appropriate licensed health professional participates in the on-site review and evaluation of residents' health status, care plans, and care provided for residents requiring specific personal care tasks.

The facility failed to ensure a Licensed Health Professional Support (LHPS) evaluation was completed for a resident requiring fingerstick blood sugar (FSBS) monitoring. Based on record reviews, the facility did not have an updated evaluation in place to support the performance of this specific health task.

The facility failed to adhere to regulations regarding admitting a resident after a notice of Suspension of Admissions was served. A review of DHSR correspondence from 10/07/24 confirmed that admissions were to be suspended immediately due to conditions detrimental to resident health and safety. However, the facility admitted Resident #4 on 01/08/25 while the suspension was in effect.

The facility failed to ensure that two exit doors accessible to a resident identified as intermittently disoriented were equipped with working alarms. Observations showed residents entering and exiting through the front door without any alarms sounding, and staff interviews confirmed the exit doors lacked alarms.

The facility failed to ensure that two exit doors accessible to a resident identified as intermittently disoriented were equipped with working alarms of sufficient volume. Observations showed residents entering and exiting the front door without any alarms sounding.

The facility failed to maintain a five-day supply of non-perishable foods. Observations and interviews indicated the food pantry did not meet the required supply levels based on the facility's census and menus.

The facility failed to provide the required minimum of 14 hours of planned group activities per week to promote socialization and physical interaction. Observations and interviews revealed no activity calendar was posted, and residents spent most of their time watching television or smoking. The Co-Administrator admitted that an activity calendar had not been completed in over two months.

The facility failed to ensure a minimum of 14 hours of planned group activities per week that promote socialization, physical interaction, and skill learning. Specifically, no activity calendar was posted, and no activities were offered to residents during the inspection period.

The facility failed to administer medications in accordance with physician orders for one resident. A dose of fluphenazine 2.5mg scheduled for 12:00 PM was not being administered as ordered due to an unauthorized medication release arrangement with a Day Program.